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LIBRARY OF CONGRESS. 



Chap.„..}. J _ Copyright No 



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UNITED STATES OF AMERICA. 



THE MEDICAL DISEASES OF CHILDHOOD 



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THE MEDICAL DISEASES 
OF CHILDHOOD 



BY 



NATHAN OPPENHEIM 

A.B. (Harv.), M.D. (Coll. P. & S., N.Y.) 

AUTHOR OF " THE DEVELOPMENT OF THE CHILD " 

ATTENDING PHYSICIAN TO THE CHILDREN'S DEPARTMENT 

OF MT. SINAI HOSPITAL DISPENSARY 



WITH ONE HUNDRED AND ONE ORIGINAL ILLUSTRATIONS 
IN HALF-TONE, AND NINETEEN CHARTS 



THE MACMILLAN COMPANY 

LONDON: MACMILLAN & CO., Ltd. 
1900 

All rights reserved 



TWO COPI ES REOEIVBD, 

APR 4 - 1900 

««8ltt.r of C.pyrigfc^ 









56758 



Copyright, 1900, 
By THE MACMILLAN COMPANY. 



SECOND COPY, 



J. S. Cushing & Co. — Berwick & Smith \k I_ I in 



Norwood Mass. U.S.A. 






TO 

THE HONORED MEMORY OF 



Jig Parent* 



PREFACE 

A work on the diseases of children which will tend to promote 
a greater use of logic and a lessened reliance upon empirical 
methods than have formerly been common, may always be sure 
of a place in the medical world. Such improvements in method 
represent one of the most desirable advances in scientific work 
and are equally important with the discovery of details in thera- 
peutics or new facts in pathology ; for they all have in view the 
recognition of diseased conditions and their prevention or suc- 
cessful treatment. The tendency of our thought in the present 
time is in the direction of the accurate recognition of abnormal 
conditions ; for when this is accomplished, the treatment, so far 
as it is elaborated, follows as a matter of course. For this rea- 
son the greatest stress in modern medicine has been laid upon the 
necessity of depicting lesions in the most graphic manner possible. 
Following out this idea, the whole available space for illustra- 
tions in this book has been given up to photomicrographs of 
pathological sections, which have been thought to have a keener 
and greater didactic value than pictures of instruments, photo- 
graphs of patients, and representations of surface changes, all of 
which must, on account of the limitations of fidelity in reproduc- 
tion, convey either a trivial or one-sided impression. As a 
resulting consideration, if the student or physician can be made 
to have a clearer conception of the difference between the healthy 
and unhealthy condition, if he can in any degree be made to 
understand better than before the phases of change which occasion 
interferences with functional activity, he will have made a profit- 
able step in the direction of efficiency and can more thoroughly 
subserve his patient's interest as well as his own satisfaction. 

Another change which has been made in this book is the plac- 
ing of statistics among matters of minor importance. In collecting 
the material for the work the compilation of statistical returns re- 
ceived much attention ; as research progressed, a feeling of dissatis- 



viii PREFACE 

faction with the results and uncertainty in regard to their reliability 
grew with an even growth. The author soon recognized that the 
widely separated sources and varying methods of diagnostication 
and treatment made more than an approximate approach to the 
truth almost beyond expectation. As an example, one may cite 
the case of diphtheria. In this disease, unless a culture and micro- 
scopical examination of the bacteria are made, the possibility of 
mistaken diagnostication is often great. The clinical evidence 
is commonly insufficient ; and since most reports have been 
founded upon such evidence alone, and since in former times 
this evidence was the only means of definition possible, the errors 
in compiling statistics must necessarily be great. There is yet 
another and even greater source of mistakes : we know that in 
diphtheria an infection of the lungs by pneumococci or streptococci 
resulting in a broncho-pneumonia is comparatively common. If 
death results in spite of the use of antitoxic serum, should it be 
attributed to the general diphtheritic invasion, the presence of the 
pneumococcus, or that of the streptococcus ? If the diphtheria 
itself was the primary cause of death, how far was it helped by 
the pneumococcus or the streptococcus, or both ? And it is even 
probable that in many of these cases the streptococcus was the fatal 
agent although they are classified in the mortality of diphtheria. 
The overweening importance of environment and the unreliable 
nature of statistical reports are shown again by the discrepancy 
between the general mortality of from 14 per cent to 20 per cent 
collected from hospitals and boards of health on the one hand, 
and on the other, the experience of reasonably able and con- 
scientious physicians in private practice, whose results are no 
more than one-third or one-quarter of these figures. The same 
or similar doubts arise in almost every other common disease in 
which the opportunities for careful investigation are abundant. 
And therefore it has seemed advisable to omit the formidable 
arrays of figures, which are copied by one author after another, as 
being far from conclusive, leading to inaccuracies, and bolstering 
up a spirit that is unscientific. 

Another omission, which was made after careful consideration, 
involves the citing of the various authorities upon whose work 
many statements have been founded. This is permissible because 
in the large brotherhood of science there is no distinct ownership, 
and one man takes up the work of another, completing or merely 



PREFACE ix 

utilizing it, without regard to the responsibility of its beginning or 
its end. We are all borrowers from one another, and we all live in 
a condition of joint ownership. The citation of references does 
not by any means do full justice to the real doers of the work in 
question ; and what is of great importance, it interferes seriously 
with the narrative quality and easy understanding of the text. 

The author wishes to record his thanks to Dr. Charles A. Els- 
berg for many acts of helpfulness in the preparation of the work 
and the correction of proof. To Dr. Morris Manges recognition 
is to be made for preparing the section from which the frontis- 
piece was made. Finally, the author takes pleasure in expressing 
his obligation to the publishers for their consistently liberal and 
sympathetic attitude in all the details of printing and publishing 
the book. 

50 East 79th Street. New York. 



TABLE OF CONTENTS 



PAGE 

Preface v 

CHAPTER I 
Development 1 

CHAPTER II 
General Hygiene of the New-born Child 24 

CHAPTER III 

Method of Examination and Diagnostic Suggestions ... 29 
Therapeutic Suggestions. Glycosuria. Anuria. Polyuria. 

CHAPTER IV 

Congenital Malformations and Deformities 38 

The Brain. The Spinal Cord. The Larynx and Trachea. The 
Lungs. The Heart. The Mouth. The CEsophagus. The Stom- 
ach. The Intestines. The Peritonaeum. The Liver. The Spleen. 
Pancreas. The Suprarenal Capsules. The Kidneys. The Urinary 
Bladder. The Urethra. The Vulva. The Vagina. The Uterus. 
The Ovaries. The Fallopian Tubes. The Mamma. The Penis. 
The Testicles. Congenital Dislocations. 

CHAPTER V 

Injuries and Diseases of the New-born 53 

Caput Succedaneum. Cephalhematoma. Hematoma of the Sterno- 
cleido-mastoid Muscle. Visceral Haemorrhage in the New-born. 
"Hemorrhagic Disease" of the New-born. Obstetric Paralyses. 
Asphyxia. Congenital Atelectasis. Icterus Neonatorum. Acute 
Pyogenic Infection. Ophthalmia Neonatorum. Infectious Hemo- 
globinemia. Fatty Degeneration of the New-born. Pemphigus 
in Infants. Umbilical Polypus. Diverticulum Tumor of the 
Umbilicus. Umbilical Hernia. Mastitis. Intestinal Obstruction 
in the New-born. Hernia of the Diaphragm. Sclerema Neonato- 
rum. (Edema. 



xii TABLE OF CONTENTS 



CHAPTER VI 

PAGE 

Feeding 72 

Substitute Feeding. Infant Foods. Care of Premature Infants. 
Weaning. Feeding during Second Year and its Continuance. 
Feeding in Acute Sickness. Dentition. 



CHAPTER VII 

Diseases of the Mouth and (Esophagus 101 

Pathological Conditions of the Lips. Hare-lip and Cleft Palate. 
Gangrene of the Cheek. Simple Erosions of the Mouth. Ulcera- 
tive Gingivitis. Simple Acute Stomatitis. Herpetoid Stomatitis. 
Mycetogenetic Stomatitis. Croupous Stomatitis. Gonorrhoeal 
Stomatitis. Simple Superficial Glossitis. Acute Glossitis. Acute 
Oesophagitis. Retro-cesophageal Lymph-adenitis. 



CHAPTER VIII 

Diseases of the Stomach and Small Intestine .... 117 
Acute Functional Derangement of the Stomach. Acute Gastritis. 
Croupous Gastritis. Toxic Gastritis. Chronic Gastritis. Dilata- 
tion of the Stomach. Ulcer of the Stomach. Hemorrhagic Ero- 
sions of the Gastric Mucous Membrane. Gastralgia. Haematemesis. 
Duodenitis. Chronic Duodenitis. 



CHAPTER IX 

Diseases of the Pancreas, Liver, and Spleen .... 136 
The Pancreas. Icterus. Functional Derangements of the Liver. 
Congestion of the Liver. Parenchymatous Hepatitis. Purulent 
Hepatitis. Interstitial Hepatitis. Acute Yellow Atrophy of the 
Liver. Fatty Liver. Amyloid Degeneration of the Liver. Echino- 
coccus Infection of the Liver. Wounds of the Liver. Subphrenic 
Abscess. Biliary Calculi. Congestion of the Spleen. Amyloid 
Degeneration of the Spleen. Parasites of the Spleen. Wounds of 
the Spleen. 

CHAPTER X 

Diseases of the Large Intestine 153 

Acute Ileo-colitis. Chronic Ileo-colitis. Ileo-colitis due to Amoebic 
Infection. Infectious Derangements of the Intestines. Subacute 
Intestinal Infection. Chronic Functional Derangement of the 
Intestines. 



TABLE OF CONTEXTS xiii 



CHAPTER XI 

PAGE 

Diseases of the Large Intestine {Continued') 177 

Intussusception. Volvulus. Animal Parasites of the Intestines. 
Intestinal Colic in Infants. Habitual Constipation. Appendicitis. 
Proctitis. Prolapse of the Anus and Rectum. Rectal Polypus. 
Fissure of the Anus. 



CHAPTER XH 

Diseases of the Peritonaeum 202 

Ascites. Acute Peritonitis. Chronic Peritonitis. 

CHAPTER XIII 

Diseases of Malnutrition ; 209 

Laryngismus Stridulus. Simple Atrophy. Rachitis. Infantile Scurvy 
(Barlow's Disease). 

CHAPTER XIV 

Diseases of the Xose and Throat 229 

Acute Rhinitis. Epistaxis. Xasal Polypi. Adenoid Vegetations of 
the Pharyngeal Vault. Acute Simple Tonsillitis. Acute Follicular 
Tonsillitis. Chronic Inflammation and Hypertrophy of the Ton- 
sils. Peritonsillar Abscess. Uvulitis and Elongated Uvula. Acute 
Pharyngitis. Chronic Pharyngitis. Retro-pharyngeal Lymph- 
adenitis. Acute Laryngitis. Chronic Laryngitis. Spasmodic 
Laryngitis. (Edema of the Glottis. 

CHAPTER XV 

Diseases of the Bronchi, Lungs, and Pleura 255 

Acute Bronchitis. Chronic Bronchitis. Acute Broncho-pneumonia. 
Chronic Broncho-pneumonia. Interstitial Pneumonia. Secondary 
Pneumonia. Bronchiectasis. Acute Pleurisy. Atelectasis. Em- 
physema. Gangrene of the Lungs. 

CHAPTER XVI 

Diseases of the Heart 301 

Functional Cardiac Disorders. Myocarditis. Acute Endocarditis. 
Chronic Endocarditis. Malignant or Mycotic Endocarditis. Car- 
diac Hypertrophy and Dilatation. Anaemic Murmurs. Peri- 
carditis. Chronic Pericarditis. 



xiv TABLE OF CONTENTS 



CHAPTER XVII 

PAGE 

Diseases of the Blood 329 

Simple Secondary Anaemia. Chlorosis. Pernicious Anaemia. In- 
fantile Pseudo-leucaemic Anaemia. Leucocythaemia. Pseudo-leu- 
caemia (Hodgkin's Disease). Haemophilia. Purpura. 

CHAPTER XVIII 

Diseases of the Genito-Urinary System . . . . . . 352 

Functional Derangement of the Bladder. Acute Cystitis. Chronic 
Cystitis. Incontinence of Urine. Vesical Calculi. Balanitis. 
Phimosis. Paraphimosis. Urethritis in Male Children. Vulvo- 
vaginitis. Stricture of the Urethra in Boys. Orchitis and Epi- 
didymitis. Hydrocele. 

CHAPTER XIX 

Diseases of the Genito-Urinary System {Continued'). Diseases of 

the Kidneys . '. 365 

Acute Congestion of the Kidneys. Acute Degeneration of the Kid- 
neys. Acute Exudative Nephritis. Acute Diffuse Nephritis. 
Chronic Congestion and Degeneration of the Kidneys. Chronic 
Diffuse Nephritis without Exudation. Suppurative Nephritis. 
Chronic Pyelo-nephritis. Amyloid Degeneration of the Kidney. 
Infarction of the Kidney. Perinephritis. Hydronephrosis. Para- 
sites of the Kidney. New Growths of the Kidney. Renal Calculi. 

CHAPTER XX 

The Specific Infectious Diseases ....... 390 

Scarlet Fever. Measles. Rubella. Varicella. Variola. Vaccinia 
and Varioloid. Diphtheria. Epidemic Infectious Parotitis. Per- 
tussis. Epidemic Influenza. Lobar Pneumonia. Enteric Fever. 
Erysipelas. Tetanus. Epidemic Cerebro-spinal Meningitis. 

CHAPTER XXI 

The Specific Infectious Diseases {Continued) 484 

Tuberculosis. Inherited Syphilis. Malaria. Weil's Disease. 

CHAPTER XXII 

Nervous Diseases 537 

Acute Leptomeningitis. Pachymeningitis. Spinal Meningitis. Sy- 
ringomyelia. Myelitis. Compression of the Spinal Cord. Infantile 



I 



TABLE OF CONTENTS xv 



Spinal Paralysis. Multiple Neuritis. Progressive Muscular Atro- 
phies. Hereditary Ataxias (Friedreich's Disease, Marie's Disease, 
Hereditary Ataxic Paraplegia). Acute Ascending Paralysis. In- 
fantile Cerebral Paralysis. Thrombosis of the Intracranial Arte- 
ries. Abscess of the Brain. Tumors of the Brain. Tumors of 
the Spinal Cord. Hydrocephalus. Asthma. Hay Fever. Sporadic 
Cretinism. Amaurotic Family Idiocy. Idiocy. Insanity in Child- 
hood. Functional Aphasia. Deficiency of Speech from Peripheral 
Paralysis. Lisping. Stuttering. Stammering. Backwardness in 
acquiring Speech. Echolalia. Coprolalia. Disorders of Speech. 
Adventitious Sucking. Masturbation. Deaf-mutism. Convul- 
sions. Epilepsy. Chorea. Tetany. Hysteria. Headaches. 

CHAPTER XXIII 

Diseases of Obscure Origin 608 

Diabetes Mellitus. Rheumatism. Rheumatoid Arthritis. Acute 
Arthritis of Infants. 

CHAPTER XXIV 
Inflammations of the Middle Ear ...... 617 



CHAPTER XXV 

Diseases of the Skin 621 

Scleroderma. Seborrhcea. Hyperidrosis. Erythema. Miliaria. 
Eczema. Simple Herpes. Herpes Zoster. Impetigo Contagiosa. 
Dermatitis Exfoliativa Neonatorum. Dermatitis Gangrenosa In- 
fantum. Urticaria. Furunculosis. Lentigo. Icthyosis. Verruca. 
Nsevus Pigmentosus. Alopecia Areata. Ringworm. Favus (Tinea 
Favosa). Scabies. Pediculosis. 



LIST OF ILLUSTRATIONS 

Sagittal Section of Human Foetus (about 4£ months) . . Frontispiece 

FIG. PAGE 

1. Diagram of Temporary or "Milk" Teeth in the Order of Eruption . 100 

2. Diagram of Permanent Teeth in the Order of Eruption . . . 100 

3. Croupous or Membranous Oesophagitis 114 

4. Normal Stomach 117 

5. Acute Gastritis 119 

6. Acute Catarrhal Gastritis 120 

7. Croupous or Membranous Gastritis 122 

8. Chronic Gastritis 125 

9. Normal Liver 137 

10. Hypertrophic Cirrhosis of the Liver (early stage) .... 141 

11. Interstitial Hepatitis 142 

12. Acute Yellow Atrophy of the Liver 144 

13. Fatty Liver 145 

14. Amyloid Degeneration of the Liver 146 

15. Normal Spleen . . . 149 

16. Congested Cavernous Yein of Spleen 150 

17. Chronic Interstitial Splenitis (Sago Spleen) 151 

18. Normal Intestine 153 

19. Catarrhal Enteritis 154 

20. Ulcer of Ileum 155 

21. Ulcerative Colitis 156 

22. Croupous or Membranous Ileo-colitis 157 

23. Membranous or Croupous Colitis 158 

24. Chronic Catarrhal Colitis 162 

25. Amoebic Ulcer of Colon 165 

26. Pulse, Respiration, and Temperature Chart of Intestinal Intoxication. 

Age, 4 years 167 

27. Acute Appendicitis 193 

28. Rectal Polypus 200 

29. Perihepatitis, occurring with Chronic Peritonitis .... 206 

xvii 



—___■■■ 



xviii LIST OF ILLUSTRATIONS 

FIG. PAGE 

30. Perisplenitis, occurring with Chronic Peritonitis 207 

31. Formal Bone 215 

32. Rachitic Bone 216 

33. Polypus of Nasal Mucous Membrane 233 

34. Acute Tonsillitis 237 

35. Normal Lymph Node 245 

36. Suppurative Lymph Node 246 

37. Pulse, Respiration, and Temperature Chart of Acute Bronchitis. 

Age, 7 months , 258 

38. Normal Lung 264 

39. Broncho-pneumonia 265 

40. Pulse, Respiration, and Temperature Chart of Broncho-pneumonia. 

Age, 13 months 268 

41. Chronic Interstitial Pneumonia 275 

42. Normal Pleura 280 

43. Fibrinous (Adhesive) Pleuritis 283 

44. Pulse, Respiration, and Temperature Chart of Purulent Pleurisy. 

Age, 8 months 287 

45. Chronic Pleurisy 291 

46. Atelectasis with Compensatory Emphysema 293 

47. Emphysema 295 

48. Gangrenous Abscess of Lung 299 

49. Normal Heart Muscle . . .302 

50. Parenchymatous Myocarditis . . 303 

51. Interstitial Myocarditis ..... r 304 

52. Valve in Acute Endocarditis . . . . . . . . 306 

53. Cirrhosis of the Liver. Passive Congestion from Mitral Stenosis . 312 

54. Pneumonia of Endocarditis 314 

55. Aortic Valve : Acute Mycotic Endocarditis 316 

56. Pulse, Respiration, and Temperature Chart of Malignant Endocarditis. 

Age, 9 years 317 

57. Normal Pericardium 322 

58. Simple or fibrinous Pericarditis 323 

59. Acute Sero-fibrinous Pericarditis 324 

60. Acute Fibrino-purulent Pericarditis 325 

61. Liver in Pernicious Anaemia 336 

62. Kidney : in Leucocythaemia 341 

63. Normal Kidney 366 

64. Acute Diffuse Nephritis, showing Plasma Cell Infiltration . . . 370 

65. Chronic Passive Congestion of Kidney (Casts in situ) .... 373 



LIST OF ILLUSTRATIONS xix 

FTG. PAGE 

66. Chronic Diffuse Nephritis without Exudation; Connective Tissue 

and Atrophied Glomerulus 375 

67. Chronic Diffuse Nephritis without Exudation 376 

68. Chronic Diffuse Nephritis with Exudation. Hyaline Glomeruli . . 377 

69. Chronic Diffuse Nephritis with Exudation 378 

70. CEdema of Lung; in Chronic Diffuse Nephritis with Exudation . . 379 

71. Amyloid Degeneration of Kidney, showing Glomerulus . . . 382 

72. Infarction of the Kidney (Endocarditis and Broncho-pneumonia) . 383 

73. Large Round Cell Sarcoma of Kidney 387 

74. Acute Scarlatinal Nephritis 394 

75. Acute Hemorrhagic Scarlatinal Nephritis : Glomerular Thrombosis 395 

76. Pulse, Respiration, and Temperature Chart of Scarlet Fever. Age, 

5 years 397 

77. Pulse, Respiration, and Temperature Chart of Scarlatinal Nephritis. 

Third and Fourth Week of Scarlet Fever. Age, 3j years . . 400 

78. Pulse, Respiration, and Temperature Chart of Measles. Age, 4 years 408 

79. Pulse, Respiration, and Temperature Chart of Measles. Acute 

Broncho-pneumonia. Age, 2 years 410 

80. Pulse, Respiration, and Temperature Chart of Varioloid. Age, 4 years 427 

81. Diphtheritic Inflammation of Pharynx 429 

82. Diphtheritic Inflammation of Trachea 430 

83. Lymphadenitis of Diphtheria 431 

84. Pulse, Respiration, and Temperature Chart of Diphtheria. Age, 

5 years 434 

85. Epidemic Infectious Parotitis (Mumps) 441 

86. Pulse, Respiration, and Temperature Chart of Influenza. Age, 

10 years 450 

87. Lobar Pneumonia : First Stage <. 454 

88. Lobar Pneumonia : Second Stage 455 

89. Lobar Pneumonia : Third Stage 456 

90. Lobar Pneumonia : Third Stage (Fibrin Threads) .... 457 

91. Pulse, Respiration, and Temperature Chart of Lobar Pneumonia. 

Age, 11 months 459 

92. Typhoidal Swelling of Lymph-node 465 

93. Typhoidal Ulceration of Intestine. Healing Stage .... 466 

94. Pulse, Respiration, and Temperature Chart of Mild Typhoid. Age, 

4 years 468 

95. Normal Cerebral Meninges 471 

96. Epidemic Cerebro-spinal Meningitis 480 

97. Acute Miliary Tuberculosis of the Lung 488 



xx LIST OF ILLUSTRATIONS 

FIG. PAGE 

98. Chronic Tubercular Pneumonia with Cheesy Degeneration . . 489 

99. Chronic Pulmonary Tuberculosis with Conservative Fibrosis . . 490 

100. Tuberculosis of Lymph-node 491 

101. Tuberculosis of the Kidney 492 

102. Miliary Tuberculosis of the Liver 493 

103. Acute Miliary Tuberculosis of the Spleen 494 

104. Tubercular Ulcer of Ileum . . . 495 

105. Tubercular Meningitis 496 

106. Tubercular Pericarditis 497 

107. Pulse, Respiration, and Temperature Chart of General Miliary 

Tuberculosis. Age, 7 years . 500 

108. Pulse, Respiration, and Temperature Chart of Tubercular Menin- 

gitis, First and Second Weeks. Age, 5 years .... 507 

109. Infantile Hereditary Syphilis of Lung 518 

110. Gumma of Spleen 519 

111. Gumma of Liver . 520 

112. Syphilitic Cirrhosis of the Liver 521 

113. Induration of Kidney : Hereditary Syphilis . . . . . 522 

114. Syphilitic Lymphadenitis . . 523 

115. Spleen in Acute Malaria 529 

116. Pulse, Respiration, and Temperature Chart of Intermittent Fever. 

Age, 6 years 530 

117. Pulse, Respiration, and Temperature Chart of Tertian Intermittent 

Fever. Age, 9 years 531 

118. Compression of the Spinal Cord: Degeneration of Descending 

Columns 547 

119. Organizing Thrombus in Vein ■ . . 562 

120. Neuro-giioma of Brain 568 

121. Pulse, Respiration, and Temperature Chart of Chorea, Lobar Pneu- 

monia, Hyperpyrexia, Death. Age, 6 years 599 



1 



THE MEDICAL DISEASES OF CHILDHOOD 



CHAPTER I 

DEVELOPMENT 

The ideal of the normal child is, and must be, the basis of in- 
telligent appreciation of the pathological processes which occur 
in his body and mind; for without a distinct idea of an ordinary 
condition, one is unable to distinguish clearly the character of 
the innumerable extraordinary states which constitute what is 
called disease. This is of even more importance in the child 
than in the adult, since the former does not represent a fixed and 
definite entity, that is the same yesterday, to-day, and to-morrow, 
as is the latter, but on the contrary is a mutable being, an organic 
flux, changing from week to week and month to month in the 
endeavor to obtain a permanent economy that is sufficient for 
the work of self-preservation and propagation of kind. This 
series of changes does not begin and end at birth ; rather does 
it start at the moment of conception, develop with wondrous 
rapidity, and finally terminate in that dim region where absolute 
maturity fades away with physical and mental decadence. Many 
of the stages are unknown or at best partly known ; but those 
which lie open and exposed before us show enough of the truth 
to indicate what the unknown remainder must necessarily be. 
The more thoroughly one becomes acquainted with the child, the 
more one is impressed with the idea that he is a creature of in- 
finite variety who bears to the adult a relation of potentiality, 
but nothing more. One can go ever farther and not only make 
a clear distinction between the child and the adult, but also dif- 
ferentiate between the child and the child. Although the study 
would be endless, nevertheless there is a logical necessity for it, 
and without it our knowledge of the subject in hand must be par- 
tial. This is demonstrated in Vierordt's table, which, although 
provisional and even fragmentary, nevertheless has much philos- 
ophy hidden in its dry figures. 

B 1 



THE MEDICAL DISEASES OF CHILDHOOD 



Weight of Organs reckoned in Percentage of Weight of Body 















Supra- 


Number 


Brain 


Thymus 


Lungs 


Heart 

0- 


Liver Spleen 
- 2 months 


Kidneys 


renal 

Capsules 


of 

Cases 


18.3 


0.15 


2.84 


0.73 

2_ 


5.08 0.63 
-4 months 


1.1 


0.25 


5 


19.3 


0.14 


3.46 


0.89 
4- 


4.86 0.45 
- 6 months 


1.2 


0.20 


7 


16.99 


0.10 


2.98 


0.68 
6- 


5.04 0.39 
- 9 months 


1.1 


0.13 


10 


17.31 


0.049 


2.6 


0.73 
9 — 


4.87 0.35 
12 months 


1.28 


0.099 


6 


16.47 





2.9 


0.71 


5.3 0.47 


1.27 


0.15 


5 


15.85 


0.079 


3.1 


1- 

0.72 


- 1^ years 
5.22 0.469 


1.22 


0.093 


6 


15.65 


0.09 


2.56 


0.69 


— 2 years 
5.17 0.46 


1.10 


0.094 


6 


11.28 


0.17 


3.06 


9 _ 
0.69 


- 2 \ years 
5.68 0.59 


1.20 


0.077 


6 


13.36 


0.093 


3.79 


2* 

0.79 


— 3 years 
5.63 0.49 


1.21 


0.073 


5 


12.66 


0.034 


3.74 


3 
0.72 


— 4 years 
5.03 0.49 


1.12 


0.068 


3 


19.6 


0.03 


6.6 


0.75 


6 years 
6.0 0.64 


1.11 


0.04 


1 



Such a demonstration is interesting in itself, and it becomes 
still more so when it is considered in relation to a table which 
shows the difference in percentage of the weight of the various 
organs in the new-born child and the adult. 




Adult 



Skeleton . . 
Muscles . . . 
Skin .... 
Brain .... 
Spinal Cord 
Eyes .... 
Salivary Glands 
Thyroid Gland 
Lungs . . . 



15.35% 
43.09 

6.3 

2.37 

0.067 

0.023 

0.12 

0.05 

2.01 



* Vierordt. 



DEVELOPMENT 




Heart 

Thymus 

Stomach and Intestines 

Pancreas 

Liver 

Spleen 

Suprarenal Capsules . 

Kidneys 

Testicles .... 



While these variations are truly striking, they could be made 
even more so if one wished to include the analysis from still more 
widely separated extremes in life. For example, one might cite 
the contrasting percentages of water in the very young foetus, 
ninety-seven and five-tenths per cent, with that of the new-born 
child, seventy-four and seven-tenths per cent, and finally with what 
exists at mature age, fifty-eight and five-tenths per cent. All along 
the line the most salient differences appear, so that in the most gen- 
eralized as well as particularized details the child is not a man in 
small, but to all intents a different being. Thus, if the propor- 
tions of the infant were multiplied to equal those of the adult, 
the huge head, the undeveloped lower face, the apex-like thorax', 
the dwarfed arms and legs, would make the impression of gro- 
tesqueness. Even the respiration is different, for in the infant it 
is diaphragmatic and does not become costal until after the 
seventh year, although even at that time it does not assume its 
fully matured type. In the early times of life it is, moreover, 
irregular, assuming a rhythmical character only in sleep. A still 
stranger fact is, that the lungs do not expand equally, and at 
times one of them may for a variable period be quiescent. The 
frequency of respiration, decreasing from thirty-five per minute at 
birth to twenty per minute at twelve years of age and eighteen at 
maturity, is in itself capable of a wide interpretation. And the 
notable rapidity of the pulse shortly after birth, the ease with 
which it is made still faster, and its naturally irregular character 
would in a person of greater age be pathological. The same 
feature of continuous change applies to every part of the organism 
and at the same time explains characteristics that are peculiar 



4 THE MEDICAL DISEASES OF CHILDHOOD 

to the infant. Thus, for instance, he is more supple than the 
adult because, comparatively, he has a larger proportion of muscle- 
tissue and a smaller proportion of tendon ; the muscles contain 
more water, a smaller amount of myosin, extractives, fats, and 
inorganic salts. Somewhat similar conditions may be seen in 
the cartilages, which increase their proportion of mineral salts 
from two and twenty-four hundredths per cent at six months of 
age to seven and twenty-nine hundredths per cent at nineteen 
years. A more detailed demonstration of the general truth may 
be made from the analysis of any characteristic bone, such, for 
instance, as the tibia : — 





2 MOS. 


9 MOS. 


3 YES. 


19 YRS. 


25 YES. 


Phosphate of Calcium . . 


57.54 


48.55 


59.74 


54.84 


57.18 


Carbonate of Calcium . . 


6.02 


5.79 


6.00 


10.82 


8.95 


Phosphate of Magnesia . . 


1.03 


1.00 


1.34 


1.26 


1.70 


Chloride of Sodium . . . 


0.73 


1.24 


0.63 


0.76 


0.60 


Cartilaginous Substance . 


33.861 


41.50 


31.34 


31.37 


29.54 


Fatty Matter 


0.82 


1.92 


0.95 


0.92 


1.84 


Organic Matter .... 


34.68 


43.42 


32.29 


32.29 


31.36 


Inorganic Matter .... 


65.32 


56.36 


67.71 


67.71 


68.42 



Not only the bones but the periosteum as well are more vascu- 
lar in the infant than the adult, and the periosteum is, likewise, 
thicker in the former. The medullary canals contain a reddish 
oily fluid that finally develops into mature marrow. Its early 
color, which is most intense at the centre, is derived from its in- 
jected vessels. The change to the normal hue, structure, and con- 
sistency begins at the centre and spreads to the periphery, reaching 
the extremities of the long bones last of all. This development 
begins in the distal bones and thence advances centripe tally. The 
gradual but radical variations are seen nowhere more plainly than 
in the skull. At first the base is almost flat ; then there is a sud- 
den rise of the basilar process in front of the foramen magnum 
with the formation of the angle between it and the body of the 
sphenoid, supplemented finally by the marked descent of the vomer, 
which originally was almost horizontal. The cause of this flatness 
of the base is the fact that in the later months of foetal life this 
part does not grow as rapidly as the upper part of the cranium, 



DEVELOPMENT 5 

which maintains its preponderance for the first few years. In 
the infant the squamous portion of the temporal bone is, as com- 
pared to the parietal, comparatively small, and does not override 
the latter. As the adult characteristics begin to assert themselves, 
the squamous suture begins to rise ; simultaneously the base attains 
a higher rate of development than the upper portion of the cranium ; 
the squamous portion approaches the vertical portion and so rap- 
idly increases in size that instead of lying below the outer margin 
of the parietal it extends so far upward that it reaches and finally 
overlaps the contiguous edge. All the changes progress, not only 
gradually, but very irregularly, thus leaving the way open for end- 
less complicating conditions ; and in the midst of the mass of iso- 
lated facts it is hard to discern the philosophy of the matter. 
Thus, while the fontanelles ordinarily disappear by the time a 
child is four years old, the sphenoid and occipital bones, with the 
layer of cartilage between them, do not fully unite at their basilar 
parts until about the age of twenty or twenty-one years. In an- 
other part, the orbital plate of the frontal bone, the process of 
ossification is regularly incomplete even after puberty, and the 
patency of the petro-squamOus suture in the roof of the tympanum 
in early life is well known, being the path of infection from the 
lining membrane of the cavity to the dura mater. In still another 
part of the face and head, the upper and lower jaws, the progress 
is very steady, but, nevertheless, the rami do not obtain their 
proper direction for a long time ; and the upper jaw, especially, 
although it may be regarded as the most important part of the 
face, does not obtain its full development until puberty or even 
thereafter. In short, the general dimensions of the infantile and 
adult skulls are essentially different : in the former the greatest 
diameter equals or exceeds the combined height of the cranium 
and face, but in the latter it is only three-quarters of the corre- 
sponding height ; again, the breadth between the outermost points 
of the infantile zygomata is to the height of the face as ten to 
four, but in the adult the proportion is as nine to eight. 

Not only does the bony skull but also its contents show a note- 
worthy distinction between the early and late forms. The first thing 
that strikes one is the fact that the dura mater in young children 
is adherent to the skull instead of, as in the mature person, being 
free, thus avoiding the collection of extravasations between it and 
the bone ; at the same time one notices that the subarachnoid space 



6 THE MEDICAL DISEASES OF CHILDHOOD 

holds more fluid than in the older persons and the brain itself is 
large but undeveloped ; chemically it contains a noticeably large 
amount of water. Naturally it is softer and of a lower specific 
gravity. Its morphological development is so slow that the cells 
of Purkinje, which are recognizable in the foetal cerebellum of 
five months, do not get all their characteristic structure for a con- 
siderable time, and it is only after birth that their inner branches 
begin to be prolonged into process-like formations extending into 
the mantel layer. Even then the developed cerebral ganglion 
cells do not exist, and may require several weeks to get a fair 
amount of growth. The cerebral convolutions are equally tardy, 
and for the period directly after the birth are indistinctly mapped 
out. From that time up to the seventh or eighth year the whole 
organ shows a rapid, although irregular, growth, the convolutions 
becoming more distinct and more deeply marked. While it is 
growing, many of its relations are changing enough to alter well- 
known landmarks. Thus the Sylvian fissure, instead of being at 
the level of the anterior part of the squamous suture between the 
temporal and parietal bones (as it is in adults), is about three- 
quarters of a centimetre above it. In another place the fissure of 
Rolando is at the beginning almost transverse in its direction and 
only after the passage of years does it acquire its true mature in- 
clination ; in addition, this fissure extends farther forward and 
downward in the infant than the adult, because the frontal lobe is 
relatively small, particularly in the third or inferior frontal con^ 
volution, and also, but to a smaller extent, in the middle frontal 
convolution. Such development is no more remarkable than that 
the frontal sinuses do not begin to appear until the second year, 
or the sphenoidal until the third, or that the foramen csecum is 
usually closed about the time of puberty. Facts like these are 
easy to multiply, but would demand more than their comparative 
share of space and attention, for each one, if logically followed out, 
means a statement of all its altered relations ; but enough has been 
stated to show in what direction the truth lies. 

The minute changes are equally noteworthy with the gross. 
In the foetal brain the individual cells are entirely distinct and 
separated from each other. Before they can perform their func- 
tion in a reliable manner they must undergo a process of elabora- 
tion, must bud and branch, and interlace like the fine roots of a 
large plant. Even after a real growth has begun, the struggle for 



DEVELOPMENT 7 

existence among the young nerve elements goes on so sharply that 
their mere presence does not necessarily mean a coeval degree of 
function. As an example, one may cite the undeveloped conduct- 
ing fibres between the immature brain and the spinal cord. "We 
know, as a matter of research, that these cells are not thoroughly 
elaborated ; likewise, as a matter of experience, we know equally 
well that the impulses, which they later on conduct, do not exist. 
The inevitable conclusion to be drawn from this combination is 
that most of a child's earliest and many of his later movements 
are purely reflex and not the result of activity in the higher cere- 
bral centres. Experimental researches confirm this idea : Goltz re- 
moved the cerebrum of a young dog and then found that the animal 
was yet able to eat and drink, to bark, to respond to salient stimuli, 
and, in general, to accomplish the most important of its physical 
functions and instincts. Longet, having amputated a pigeon's 
cerebral hemispheres, demonstrated that the bird was able to eat 
and drink, to perform the excretory functions, to follow a moving 
light, to blink the eyes, and to accommodate the iris. 

As the brain develops, each progressing stage is marked by a 
distinct increase in the nerve-medullation. Those parts which 
first obtain their myelin sheaths are likewise the first to function- 
ate ; in this way w^e have an accurate and satisfactory method of 
ascertaining developmental progress. Consequently, we know 
that the fibres of the cord, medulla oblongata, pons Varolii, and 
corpora quadrigemina, being meclullated long before those of 
higher cerebral centres, first perform their functions. That is one 
way in which we know that a child's somatic impulses are and 
must be developed long before the most purely intellectual ones 
begin to exist. In a similar way we can understand why an in- 
fant's movements are incoordinated, uncontrolled, and purposeless, 
for the peripheral nerves become meclullated and therefore effi- 
cient long before the inhibitory centres. The same rule holds 
true not only of the main fibres but of their primary and second- 
ary branches as well. The process of growth by which the nerve 
cells put out their neurons and dendrons is a most elaborate one, 
as is conclusively demonstrated by the fact that the cell-bodies 
alone make up no more than ten per cent by weight of the central 
nervous system, while the neurons, dendrons, and like bodies con- 
stitute the remaining ninety per cent. The position of an animal 
in the vertebrate series is marked by the number of divisions and 



8 THE MEDICAL DISEASES OF CHILDHOOD 

subdivisions that characterize the branches of the cortical cells. 
Cajal's figures show that each cell begins with no branches but 
finally has many ; Vulpius and Kaes have demonstrated the steady 
and remarkable increase of these bodies, and Howell states that 
the increase continues up to the age of thirty years, being accom- 
panied by a like growth in medullation. One can easily see how 
provisional is the mental equilibrium of the child from the facts 
that the first seven years of life are largely concerned in building 
up the peripheral system, that the motor and sensory fibres con- 
stitute no more than one-third of the whole cortical surface, and 
that the development of the remaining two-thirds is prolonged 
over a much greater space of time. This slow elaboration is ac- 
companied by an equally slow appearance of chromatin granules, 
whose importance in the functional activity of nerve-structures is 
doubtless great, although at present not clearly defined. Even 
after the brain has attained a fair degree of efficient formation, the 
transitory, unstable nature of its functional activity is shown by 
Peterson when he says : "From studies I have made of hemiplegia 
in children, I have been led to conclude that during the first years 
of life (perhaps up to eight or ten or more) the two hemispheres 
share equally the motor and sensory functions of speech, and that 
it is only during adolescence that the left hemisphere (in right- 
handed persons) takes upon itself gradually the greatest part of 
this burden." 

The vertebrae show equally interesting changes with the brain 
and skull. The whole structure at birth is broader and shorter 
than in the adult, and the cord descends about one vertebra lower 
than later in life, with the natural result that the cavity of the 
spinal dura mater usually ends near the top of the third sacral 
vertebra. The whole column is very pliable and lacks the char- 
acteristic cervical and lumbar curves that come into existence with 
later growth and strength. The proportions between the different 
portions of the column are not the same as in maturity : in the 
latter case the cervical is to the lumbar part as two is to three, but 
in infants they are equal to each other ; the cervical is propor- 
tionately longer in infants, while in the late foetal and early extra- 
uterine life the proportion of the movable part of the column 
in the neck is greater than that in the loins — the reverse of the 
adult condition ; and in later childhood the lumbar portion grows 
more rapidly than the cervical, until after puberty the final pro- 



DEVELOPMENT 9 

portions begin to be marked out. The vertebral bodies do not be- 
gin to consolidate until the fourth year, and progress more or less 
regularly until the eighth and more ; this does not include the 
epiphyseal plates, which do not get their growth until about the 
seventeenth year. The coccyx is slowest of all, for its consoli- 
dation does not come about until puberty, the third piece is not 
ossified until the sixteenth, and the fourth until between the 
eighteenth and nineteenth years. 

About two-thirds of the growth of the eye belongs to early 
infancy ; but the recessus opticus is more plainly distinguishable 
at birth than at maturity. A remarkable fact is shown in the 
growth of the macula lutea, which is developed only after birth. 
The lachrymal glands are equally tardy, and for weeks or months 
are not prepared to shed tears. The ear likewise develops un- 
evenly ; while the parts of the internal ear, the ossicles and tym- 
panic cavity, are comparatively well formed a short time after birth, 
the external meatus, the mastoid portion, and the Eustachian 
tube are far from having reached their final form. The annulus 
tympanicus soon begins to grow outward to make the base and 
anterior walls of the external meatus and also forward and 
inward along the outer wall of the tympanum, at the same time 
reinforcing a small part of the outer wall of the Eustachian tube. 
The osseous meatus of the ear is not thoroughly well developed 
until about the fourth year. In infancy the auditory canal has a 
peculiar course, since it passes inward and downward while the 
drum membrane is almost horizontal. The development of the 
mastoid cells is yet later ; after birth the external petro-squamosal 
suture gradually closes up until by the end of the first year the bones 
are practically consolidated. Slowly then the mastoid process be- 
gins to form. From the periosteum and the surface there is a 
growth of new bone which slowly thickens the external and inferior 
walls of the antrum. In the new-born this wall is only about one 
or two millimetres thick, but the increase is so steady that at nine 
years of age it is nearly one centimetre. The new bone is a 
fragile and delicate cancellous structure which at the approximate 
time of puberty is eaten away by a process of absorption so that 
a number of communicating air cells are formed, each being lined 
with mucous membrane. 

Another part which shows characteristic growth is the Eusta- 
chian tube. Its nasal meatus is in the foetus lower than the 



10 THE MEDICAL DISEASES OF CHILDHOOD 

level of the hard palate; shortly after birth the two are in the 
same plane, while in the ackilt the meatus is higher by a consider- 
able space. The tube in the new-born is nearly horizontal, but it 
inclines downward in the adult. In very young children it is 
shorter than in the mature subject, but it is relatively and abso- 
lutely wider at its narrowest portion in the former than the latter. 
Daring the period of growth it doubles its length, but the aural 
meatus maintains its original size. In early infancy the nose has 
a peculiar growth. The inferior turbinated bone projects slightly 
into the nasal cavity, but there is no more than a small free space 
below and none behind it. In this part the greatest development 
may be expected. The height increases rapidly until dentition, 
then it becomes slow for a time and again grows rapidly until 
nearly the eighth year. At this time the breadth increases and 
the olfactory portion becomes larger. At a very early age the 
posterior margin of the vomer is noticeably oblique, but gradually 
with the downward growth of the face assumes a less horizontal 
slant. 

The development of no part of the body is more interesting 
than that of the teeth. The alveolar processes as early as the 
seventh foetal month show a row of indentations which corre- 
spond to the twenty milk, teeth. Slowly the crowns become 
formed and calcified, but at the same time the dental sacs of the 
permanent incisors, canines, bicuspids, and first molars begin to 
form in the jaws. The first upper molars lie behind the second 
temporary molars, but not in alveoli. There is so little free space 
that the second temporary molars in the upper jaw are set in shal- 
low depressions without posterior walls. In the inferior maxilla 
the sockets for the second temporary molars extend back to the 
coronoid processes, underneath which the first permanent molars 
are stowed. The elements of the second molars are formed be- 
fore the end of the first year, while those of the third molars do 
not appear until the fifth. All these teeth have not room to be set 
evenly side by side, in the small and undeveloped jaws, and there- 
fore we find them packed together, the central overlapping the 
lateral incisors, the canines being forced over all. The structural 
composition undergoes divers changes in such items as enamel, 
dentine, and nerve supply, so that the stored-up elements appear 
little by little as the corresponding functions grow out into 
activity. 



DEVELOPMENT 11 

During all these changes, the tongue is altering its shape and 
direction, and is steadily endeavoring to overcome its thinness, 
its long ribbon-like form. The soft palate lies very close to it, 
like a curtain, and when the mouth is closed extends backward 
rather than down, as in the adult. At the same time the uvula 
is rudimentary rather than merely small, and the follicles at the 
back of the tongue are so little developed that often they cannot 
be seen. The same may be said of the pharyngeal or third tonsil, 
which at the beginning of life is normally very small, although 
exceptional cases occur in which it is hypertrophied at or before 
birth. During the early months of infancy the ptyalin-forming 
glands are entirely inactive, and when the ferment begins to be 
formed it is weak in character and small in quantity. The sali- 
vary glands are likewise of a poor relative development, and at first 
their functional activity is practically no more than potential. 

In this early part of life one of the main characteristics is the 
unevenness, the irregularity of the growth in the various parts. 
While the development of most parts is forward, the rule does 
not apply universally. As an example one may cite the evolu- 
tion of the thymus gland. At birth it is almost as large as the 
left lung, and in addition it continues to grow for about three years. 
Then, mysteriously enough, it stops growing and remains station- 
ary until near the time of puberty, when, in the same unknown 
way, it gradually atrophies or is replaced by a mass of fat. In 
infancy it is large enough to lie in both neck and thorax, extend- 
ing down into the anterior mediastinum and resting in two long 
lobes on the pericardium ; by its relatively large size it holds the 
right and left lungs with their pleurae apart. The change by 
which it so rapidly fades into nothing is certainly remarkable. 
The thyroid gland has something of the same character on 
account of having its largest relative size in childhood ; although 
in this case the after-development is not so noteworthy as in the 
thymus. 

The neck has its peculiar evolution which maintains the idea 
of irregularity. Between birth and maturity the larynx lowers 
its relative position in the equivalent of two vertebrae and two 
intervertebral disks. Thus the top of the epiglottis descends 
from the lower border of the atlas to the centre of the third 
cervical vertebra or lower. At the same time the absolute size 
is gradually increasing. In the trachea the bifurcation at birth 



12 THE MEDICAL DISEASES OF CHILDHOOD 

corresponds in position to the third dorsal vertebra, but at 
maturity it is opposite the fourth. The upper sternal extremity 
is relatively higher as well as smaller in the infant than the adult. 
The adjacent ribs go through simultaneous changes which mark 
off one period of life from another. In the first months the third 
and fourth costal cartilages are attached in a horizontal direction 
to the sternum, but in later life they have an upward slope. The 
lower three true costal cartilages have a more horizontal course, 
and the angle which they subtend is greater in infancy than in 
maturity. The clavicles follow the same rule of horizontal 
attachment, and do not have the upward curve of the outer 
extremities that exists in adults. 

These changes necessarily indicate equally great deviations 
from the form of the adult chest. In the young child the trans- 
verse diameter increases more rapidly than the antero-posterior, 
having the relation of one to two instead of, as in the adult, one 
to three. Such reasons control the fact that the infantile thorax 
is a blunt right cone rather than the mature form of reversed 
cone. A characteristic fact is that in early life the superior 
sternal margin is about even with the centre of the second dorsal 
vertebra, but in the development of later years it sinks to the 
third dorsal vertebra. Also one may easily explain, in part, the 
barrel-shape of the child's chest and his abdominal method of 
breathing by the less oblique position of the ribs, by their being 
flatter and less hooped up than in the man. 

The heart shows some interesting and characteristic altera- 
tions in function and size. Before birth it fills up the greater 
part of the thoracic cavity ; at this time its circulation is so dif- 
ferent from the later form that it belongs to the same category 
of noteworthy transitional forms, some of which have already 
been mentioned. The blood, after passing from the placenta by 
the umbilical vein, flows to the inferior surface of the liver and 
there divides into two streams, one going through the ductus 
venosus to the inferior vena cava, the other entering the portal 
vein, from which it is distributed through the liver and finally 
empties into the inferior vena cava. Thence it flows into the 
right auricle, into which the superior vena cava directs the cur- 
rent from the head, neck, and arms. The two streams do not 
mix, the latter flowing through the auriculo-ventricular opening, 
while the former is directed by the Eustachian valve through the 



DEVELOPMENT 13 

foramen ovale into the left auricle, thence to the left ventricle, 
finally to the aorta. The current from the superior vena cava 
flows in a small part to the lungs through the pulmonary artery, 
and finally to the left auricle ; the remaining and larger part 
issuing through the ductus arteriosus finds its way into the aorta, 
where it meets that portion of the current from the inferior vena 
cava which has not entered the three great vessels of the upper 
body ; thence the two are sent to the trunk and lower extremities, 
a part reaching the placenta by the umbilical arteries, thence 
by the umbilical vein to the inferior surface of the liver. 

When the child is born and the umbilical vessels are tied, the 
foramen ovale, the ductus arteriosus and ductus venosus rapidly 
close. The two currents which flow from the superior and inferior 
vense cavse meet and mingle in the right auricle, from which the com- 
mon stream enters the right ventricle. Thence by the pulmonary 
artery it is distributed through the lungs ; it then enters the left 
auricle and finally the left ventricle, from which it is sent to the 
rest of the body. If the heart is measured at this time, its size 
will still be found relatively larger than the adult, the comparative 
dimensions being eighty-nine hundredths of one per cent of the 
body weight in the new-born infant, and fifty-two hundredths of 
one per cent in the adult ; in spite of this large size the left ven- 
tricle is about equal to the right, being as yet without the added 
growth that eventually comes to it. Examination will show a 
concomitant alteration in structural relations : if we consider the 
above-mentioned facts in relation to the known narrowness of 
the chest in the infant, and the maintenance of a similar vertical 
extent in childhood and maturity, it naturally follows that the 
transverse diameter in the child is greater than it later is. As a 
further result the apex beat is nearer the mammary line, or out- 
side of it, which is quite different from what Ave see in men and 
women. Another fact which concerns the position of the organ 
is the noticeable proximity of the conus arteriosus to the chest 
wall with the resulting " milk spot " caused by friction. All in 
all, one may say that the containing space, the relative and abso- 
lute positions, and the form of the youthful heart are plainly 
different from what they are at maturity. 

The rate of increase in the size of this organ is so irregular 
that it bears no definite relationship to the growth of as closely 
connected a system as the arteries. Thus the heart increases 



14 THE MEDICAL DISEASES OF CHILDHOOD 

rapidly in the first months of life, slowly from the third to the 
ninth or tenth year, and very rapidly during the general period of 
puberty. Thus, with the slowly developing heart there is a wide 
and active arterial system, while at puberty, with its comparatively 
large and active heart, there is a distinctly narrow arterial sys- 
tem. During this period the heart increases twelve times its 
original size, while the arteries increase to only three times their 
original proportions. Stated differently the fact would be that in 
infancy the relation of the heart's volume to the diameter of the 
ascending aorta is as twenty-five to twenty, before puberty as one 
hundred and forty to forty-six and after puberty as two hundred 
and ninety to sixty-one. A closely associated fact is the difference 
in blood pressure, for the conditions of early life make for a low 
tension, which one can see in the action of the abdominal viscera, 
while at and after puberty the tension is considerably higher. 
While the blood pressure in the infant body as a whole is low, 
that in the lungs is high — a fact that is doubtless due in part to 
the unstable and changing relations of the pulmonary artery and 
aorta which in childhood bear the relation to each other of forty to 
forty-six, but at maturity of thirty-five and nine-tenths to thirty- 
six and two-tenths. As results, there are a heightened excretion 
of carbonic dioxide, a more rapid respiration, and a greater nitro- 
gen percentage in the early condition. Another example of un- 
even local development may be seen in the abdominal aorta and 
common iliac arteries which in the first few days are greater than 
at any time for the succeeding three months. Yet another inter- 
esting fact is contained in the varying rapidity of the circulation ; 
at birth the entire round is made in about half the time required in 
the adult, but the adjustment progresses so rapidly that at three 
years of age the rate is only one-third faster. In fact, the whole 
course of the cardiac development is irregular, so that we cannot 
give a steady proportional rate between its growth and that of the 
other viscera. All that is possible is to make generalizing state- 
ments, such as, that the size of the heart in childhood is relatively 
greater than that of the lungs, or that while the heart doubles its 
size the liver increases only one-half of its volume. 

In the liver the changes are fully as noteworthy as those which 
have been considered. This organ, during the second foetal 
month, attains a relatively enormous size, in the next month it 
extends into the hypogastric region and occupies the greater part 



DEVELOPMENT 15 

of the abdominal cavity. Its decrease in size is continuous until 
at birth it constitutes one-eighteenth of the body weight, and at 
maturity one thirty-sixth. At the same time one should keep in 
mind that the change is not steady and regular, but rather that it 
occurs in fits and starts. In the adult, as every one knows, 
it ought to lie in the right side of the thorax and not extend 
below the free border of the ribs, but in infancy it is pushed down 
one, two, or more centimetres below that line, and may invade 
enough of the left thoracic region to displace both breast and 
lungs ; it may even extend so far as to fill up a noticeable part 
of the abdominal space. In its minute arrangement there is like- 
wise a characteristic slowness of development. Thus in foetal 
life there are two main varieties of hepatic cells : one a polyhedral 
form that is practically the same as the mature ; the other, which 
is probably a young type of the adult variety, is a small round 
cell that tends to disappear after birth. A considerable time 
passes before the hepatic cylinders assume the adult mammalian 
type. Slowly they become longer and narrower on account of 
a rearrangement of the cells, until the number of cells, as shown 
by cross-section, is reduced to two. Simultaneously the gall-blad- 
der changes its relations, for its fundus is farther removed from 
the anterior wall in children than in adults. The whole sys- 
tem seems to have its own rule in development, for instead of 
showing a slowly increased absolute size and a stationary relative 
condition, it exhibits a decreased relative size and an eccentric 
absolute bulk. In the secretion of bile the organ once more 
shows its peculiarity ; for this fluid appears very early, in some 
cases as soon as the third month of foetal life. In addition it 
is produced in relatively greater quantities than in the adult, and 
its consistency is thinner. While the liver is very large, and evi- 
dently very active, the spleen, although it occupies its adult 
position, is both absolutely and relative^ smaller in infancy than 
in later years. In these young children one can with difficulty 
make out its form. Likewise, it is very inactive, so that its back- 
wardness in growth accompanies a similar backwardness in func- 
tional ability. 

While the heart shows but little relation in growth to the 
liver, it shows no more to the lungs. In the time required to 
increase its size b}~ one-fifth, the lungs have added five-sevenths 
of the original volume to their dimensions. Up to the fourteenth 



16 THE MEDICAL DISEASES OF CHILDHOOD 

year these organs come into no closer relationship. The irregu- 
larity of the whole connection is shown by the fact that in infancy 
the bulk of the heart is to that of the lungs as is one to three and 
one-half or four ; but at or shortly after puberty the lungs have so 
much increased their capacity that they are to the heart as seven 
and three-tenths are to one. About this latter time the heart in 
its turn receives a strongly accelerated growth, so that within 
a short period the proportion is reduced to about one to eight- 
tenths. In a very generalized fashion one would say that the 
approximate growth of the lungs resembles that of the liver, while 
the heart develops in a comparatively similar way to the kidneys. 
The lungs in their minute structure are of decided theoretical 
and practical interest. During the first two years the walls of the 
alveoli are thick and their blood-vessels are loosely held. It is 
not until between the fourth and fifth years that the stroma has 
become tense and binding, with the adult control of the capil- 
laries, and that the developmental relations between the alveoli 
and bronchi begin to assert themselves. In infancy the under- 
lying loose tissue lining the bronchial tubes slowly binds the 
mucous membrane to the fibro-muscular wall, and then keeps 
pace in its growth with the other compact tissues, until in adult 
life it appears as dense fibrous bands. The area of bronchi and 
their divisions exceeds that of the air spaces ; the connective tis- 
sue of the parts is likewise more abundant, and easily undergoes 
a proliferation of its cellular elements ; the submucous connective 
tissue of the bronchi is loose, richly supplied with nuclei, and 
holds its capillaries in a loose grasp ; the alveoli are small, their 
lining cells are set in a continuous layer, their epithelium prolifer- 
ates abundantly, and their absorbents act slowly. During this 
period the blood-vessels play a more important part than later on, 
permitting congestive disorders with very little resistance. With 
all this rapid growth the lungs do not attain their forward expan- 
sion until seven years of age, and before that time the left lung, 
on account of the high position of the diaphragm which is charac- 
teristic of early childhood, is somewhat higher situated than the 
right. 

In the kidneys lobulation occurs in prenatal life, and continues 
for a considerable period after birth ; then the lobules slowly dis- 
appear, giving way to the newly formed pyramids of Malpighi. 
The organs are comparatively larger than in the adult, and have 



DEVELOPMENT 17 

a lower situation. This is the more remarkable since the lumbar 
spine is relatively small. At birth the two kidneys are of equal 
size, but during the first year the left one becomes larger than the 
right, and its location is slightly higher, where it remains until 
seven or eight years of age. A noteworthy fact may be seen in 
these organs in the form of infarctions which may exist for a con- 
siderable time after birth. These occur normally in foetal life, and 
sometimes persist in a form which in later years would have a 
pathological significance. It reminds one of the conical tragus so 
often seen in early childhood, which regularly occurs in prenatal 
life, or of hare-lip, which is likewise a foetal condition carried 
over into postnatal growth, or a patent foramen ovale. 

The calibre of the arterial system in the kidneys bears a some- 
what anomalous relation to these organs ; the transverse section 
of the former increases more rapidly than the volume and weight 
of the latter, with the natural result of increased tension, This 
fact has a more important bearing upon the pathological con- 
ditions of childhood and the great liability of a nephritic involve- 
ment. This large increase is in distinct contrast to some of the 
largest vessels, for instance, the carotid, in which the growth is 
relatively small, or the femoral, whose increase is no more than 
moderate. The suprarenal capsules present another example of 
eccentric development, for they are almost as large at birth as 
they are in the adult life, and in some cases they are yet larger. 
The question of their function is so obscure that one may not go 
farther than the mere statement above. 

The stomach shortly after birth grows very rapidly, but before 
many months the rate becomes considerably slower. The shape 
in infancy is more tubular, the position more vertical, the situa- 
tion higher, and the oesophageal sphincter less developed than at 
maturity. With these premises it is easy to understand why a 
baby vomits on very slight provocation and with very little dis- 
tress. Microscopically, as well as macroscopically, the structure 
is peculiar. The characteristic gastric ducts which perform so 
large a part of the organic work do not attain their full develop- 
ment until maturity ; about the time of birth each one of them 
contains about seven glands. This number is progressively 
reduced until in the adult there are only three to a duct. Peri- 
stalsis is comparatively weak, and the functional secretions are 
of a special sort, inasmuch as they have little or no corrosive 



18 THE MEDICAL DISEASES OF CHILDHOOD 

power and the capability of breaking up cell-envelopes. On the 
other hand, they contain a relatively large amount of rennet and 
a noteworthy faculty for digesting casein. The necessity of 
restricting an infant's diet to milk may thus easily be seen. The 
secretions of the pancreas similarly vary between infancy and 
maturity, for in the former the amylopsin is entirely inert and 
steapsin and trypsin scarcely active. 

The intestines grow in an irregular fashion, at one time much, 
at another time but little ; and they require considerable time 
to obtain their permanent position and fixed attachments. In 
adults there is a constriction between the first and second parts 
of the intestine which in infants is very often absent. The length 
of the large intestine does not increase during the first four 
months, but after this time the upper portion begins to grow 
rapidly and at the expense of the sigmoid flexure, which at birth 
constitutes about one-half of the whole large intestine. From 
the fifth month the sigmoid flexure, having obtained its perma- 
nent proportions, continues to grow according to the general rate 
of increase. The transverse colon is at first relatively huge ; the 
ascending colon is, on account of the higher position of the 
csecurn and the large size of the liver, very short ; it more 
often has a mesentery than in the adult and a relatively larger 
part above the csecum is covered with peritonseum. As a result 
the gut in this region is free and can change its position and 
relations to a surprising extent ; in foetal life it lies in the median 
plane and very high up. In its growth it passes to the right, in 
front of the second portion of the duodenum, and finally descends 
into the iliac fossa. The whole sigmoid flexure, even after it has 
obtained the permanent proportions, is placed so high that barely 
any of it is found in the pelvis until such later times when the pelvic 
bones are spread out. In early childhood Brunner's and Lieber- 
kuhn's glands are no more than partially developed, and the soli- 
tary and agminated glands are unusually rich in lymphoid tissue. 
The whole lymphatic system, in fact, is highly developed in the 
first part of life and contains a relatively greater amount of 
lymph in circulation than what is normal at adult age. 

The condition of the rectum may be inferred from what we 
know of the portion of the large intestine above it. The greater 
part of the rectal length is in the abdomen instead of the true 
pelvis ; it is nearly straight and occupies a fairly vertical position 



DEVELOPMENT 19 

instead of lying in the lateral and the two antero-posterior curves 
of the adult form. In children the attachments do not extend 
high up, and the reflected peritonaeum is located farther down 
than in developed persons. These facts have a strong bearing 
upon the ease of contracting chronic constipation, prolapse of the 
rectum, and digestive disorders. 

The bladder of the infant is practically an abdominal, and not 
a pelvic, viscus. Its posterior surface in the course of develop- 
ment becomes covered by peritonaeum, but its anterior surface 
remains without this covering until after puberty. The ovaries, 
uterus^ prostate gland, testicles, and male urethra cannot be 
expected to develop in any large measure until about the time 
of puberty. The perinaeum varies according to the changes in 
the neighboring structures. The pelvis increases in size very 
much, especially about the time of puberty, when the organs 
which naturally belong in it are allowed to sink into their proper 
places ; the change is naturally most plainly visible in the female 
whose broad pubic arch and wide transverse diameter (exceeding 
the antero-posterior) are characteristic of the adult condition. 

All these facts should be regarded not as the final and com- 
plete statements upon which to form the ideal of the normal child, 
but rather as isolated and characteristic observations which may 
be used as the outlines of a true picture that requires the work 
of many hands for its finishing. A full account of all the slow 
changes that make the child so widely different from the adult 
would of necessity bring in practically every element of }Dhysical 
and mental growth; but enough has been recorded and suggested 
to demonstrate that the child is not a fully formed being, that his 
development is not a rigidly immovable process, that each pro- 
gresses toward fruitful maturity slowly and irregularly, and that 
the unstable equilibrium, which perforce exists, demands intelli- 
gent and sympathetic care for its conservation. The medical care 
of children has this in view as much as the control of immediate 
pathological conditions. 



20 



THE MEDICAL DISEASES OF CHILDHOOD 



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22 



THE MEDICAL DISEASES OF CHILDHOOD 



Quetelet's Table of Average Height and Weight, 
Ten of Each Age and Sex 



Height : 


Inches 


Weight : 


Pounds 


M. 


F. 


M. 


F. 


19.7 


19.4 


6.8 


6.6 


27.5 


27.2 


21.8 


19.0 


31.1 


30.7 


24.3 


24.3 


34.0 


33.6 


27.6 


27.3 


36.5 


36.0 


30.9 


30.6 


38.9 


38.3 


35.1 


33.7 


41.2 


40.6 


39.2 


36.8 


43.5. 


42.8 


43.4 


39.2 


45.7 


45.0 


47.6 


41.9 


48.0 


47.1 


51.8 


46.3 


50.1 


49.2 


55.6 


50.9 


52.2 


51.2 


59.5 


56.2 


54.1 


53.2 


63.9 


63.9 


56.0 


55.1 


73.0 


71.7 


57.8 


56.9 


81.8 


80.0 


59.6 


58.6 


90.8 


88.2 



Age. 

years 

1| years 

2\ years 

3£ years 

4£ years 

5^ years 

6| years 

7 1 years 

8| years 

9£ years 

10^ years 

11| years 

12| years 

13^ years 

14| years 

15| years 



Table showing Weight, Height, and Circumference of the Head 
and Chest from Birth to the Fourteenth Year. 

(Boas in Scie?ice, April 12, 1895.) 





Weight 


Height 


Chest 


Head 






Pounds 


Kilos 


Inches 


Cm. 


Inches 


Cm. 


Inches 


Cm. 




Boys . . 


7.55 


3.43 


20.6 


52.5 


13.4 


34.2 


13.9 


35.5 


Birth 


Girls . . 


7.16 


3.26 


20.5 


52.2 


13.0 


33.2 


13.5 


34.5 




Boys . . 


16.0 


7.26 


25.4 


64.8 


16.5 


42.0 


17.0 


43.5 


6 months 


Girls . . 


15.5 


7.03 


25.0 


64.6 


16.1 


41.0 


16.6 


42.2 




Boys . . 


20.5 


9.29 


29.0 


73.8 


18.0 


45.9 


18.0 


45.9 


12 months 


Girls . . 


19.8 


8.84 


28.7 


73.2 


17.4 


44.4 


17.6 


44.6 




Boys . . 


22.8 


10.35 


30.0 


76.3 


18.5 


47.1 


18.5 


47.1 


18 months 


Girls . . 


22.0 


9.98 


29.7 


75.6 


18.0 


45.9 


18.0 


45.9 




Boys . . 


26.5 


12.02 


32.5 


82.8 


19.0 


48.4 


18.9 


48.2 


2 years 


Girls . . 


25.5 


11.56 


32.5 


82.8 


18.5 


47.0 


18.6 


47.2 




Bovs . . 


31.2 


14.14 


35.0 


89.1 


20.1 


51.1 


19.3 


49.0 


3 years 


Girls . . 


30.0 


13.60 


35.0 


89.1 


19.8 


50.5 


19.0 


48.4 



DEVELOPMENT 



23 



Table showing Weight, Height, etc. {continued) 





Weight 


Height 


Chest 


Head 






Pounds 


Kilos 


Inches 


Cm. 


Inches 


Cm. 


Inches 


Cm. 




Boys . . 


35.0 


15.87 


38.0 


96.7 


20.7 


52.8 


19.7 


50.3 


4 years 


Girls . . 


34.0 


15.41 


38.0 


96.7 


20.5 


52.2 


19.5 


49.6 




Boys . . 


41.2 


18.71 


41.7 


106.8 


21.5 


54.8 


20.5 


52.2 


5 years 


Girls . . 


39.8 


18.06 


41.4 


105.3 


21.0 


53.5 


20.2 


51.3 




Boys . . 


45.1 


20.48 


44.1 


112.0 


23.2 


59.1 






6 years 


Girls . . 


43.8 


19.87 


43.6 


110.9 


22.8 


58.3 








Boys . . 


49.5 


22.44 


46.2 


117.4 


23.7 


60.6 






7 years 


Girls . . 


48.0 


21.78 


45.9 


116.7 


23.3 


59.5 








Boys . . 


54.5 


24.70 


48.2 


122.3 


24.4 


62.2 






8 years 


Girls . . 


52.9 


24.01 


48.0 


122.1 


23.8 


60.8 








Boys . . 


60.0 


26.58 


50.1 


127.2 


25.1 


63.9 






9 years 


Girls . . 


57.5 


26.10 


49.6 


126.0 


24.5 


62.5 








Boys . . 


66.6 


30.22 


52.2 


132.6 


25.8 


65.6 


21.0 


53.5 


10 years 


Girls . . 


64.1 


29.07 


51.8 


131.5 


24.7 


63.0 


20.7 


52.8 




Boys . . 


72.4 


32.83 


54.0 


137.2 


26.4 


67.2 






11 years 


Girls . . 


70.3 


31.87 


53.8 


136.6 


25.8 


65.8 








Boys . . 


79.8 


36.21 


55.8 


141.7 


27.0 


68.8 






12 years 


Girls . . 


81.4 


36.90 


57.1 


145.2 


26.8 


68.3 








Boys . . 


88.3 


40.04 


58.2 


147.7 


27.7 


70.6 






13 years 


Girls . . 


91.2 


41.36 


58.7 


149.2 


28.0 


71.3 








Boys . . 


99.3 


45.03 


61.0 


155.1 


28.8 


73.3 






14 years 


Girls . . 


100.3 


45.50 


60.3 


153.2 


29.2 


74.1 








Boys . . 


110.08 


50.26 


63.0 


159.9 


30.0 


76.6 


21.8 


55.5 


15 years 


Girls . . 


108.4 


49.17 


61.4 


155.9 


30.3 


76.8 


21.5 


54.8 





CHAPTER II 
GENERAL HYGIENE OF THE NEW-BORN CHILD 

The child's care is supposed to begin as soon as the cord has 
been tied and respiration fully established. The eyes must be 
thoroughly cleansed with boric acid solution, excepting where the 
physician has reason to believe that the mother's genital track is the 
seat of infection, in which case one or two drops of a one-half per 
cent solution of silver should be instilled into the infant's eyes. 
Such children must thereafter be carefully watched lest an ophthal- 
mia be allowed to develop. The next step is to ascertain whether 
the child's mouth and throat are clean and unimpeded. The in- 
fant's body may next be anointed with oil or vaseline, he should be 
wrapped in a blanket and placed in his crib. There is no necessity 
to bathe him for the next twenty four hours. One must remember 
that a new-born babe is exceedingly sensitive, that he has before 
birth been perfectly protected from sudden changes of tempera- 
ture and exposure of all kinds, that the vernix caseosa covered 
the skin before birth and cannot possibly do harm for one day 
more, and that its removal causes unnecessary exposure at a time 
of greatest susceptibility to injurious impressions. At the end of 
the first day he may be bathed and clothed with his first gar- 
ments. 

The cord should be lightly covered with a dusting powder 
composed of boric acid and starch, and then drawn through an 
aperture in a square piece of soft gauze or lint in which it is to be 
wrapped. From time to time the cord should be inspected in 
order to see that no haemorrhage exists. Attention should like- 
wise be given to the child's heart-action and respiration, and, if 
necessary, a series of cryings must be provoked to insure full 
inflation of the lungs. When these items are in satisfactory con- 
dition, the child should be kept in the dark and allowed to sleep, 
and in the succeeding months his room during his sleep should 
always be darkened. 

24 



GENERAL HYGIENE OF THE NEW-BORN CHILD 25 

During the first clay the necessity of feeding is not great. The 
child should be once put to the breast after the mother has been 
cleansed and made comfortable, and thereafter considerable latitude 
may be allowed. Some authorities order nursing every six hours 
for the first clay, every four hours for the second, and on the third 
every two hours, this last rate being continued during the first 
weeks. But with many children there is little need of giving more 
than one or two feedings the first day. Two or three teaspoonf ids 
of boiled water may be given if the infant is restless. On the second 
day three or at the most four nursings may be required; and on 
the third the regular interval of two hours should be instituted. 
From the first the child should be trained to require the minimum 
of nursing at night; and even when he is fed every two hours by 
clay, he must be accustomed to an interval of quiet for six hours 
at night, during which he and his mother may sleep. Another 
very important matter connected with nursing is that of clean- 
liness of the mouth. Every day the cavity must be carefully but 
gently washed out with a solution of boric acid; if this is done 
lightly enough, the child's mouth may be washed before each 
feeding without in the least injuring the delicate mucous mem- 
brane. This measure will naturally be of no avail unless the 
mother's nipple is likewise rendered clean. This may easily be 
accomplished by washing it before and after nursing with boric 
acid solution and at least once a clay with alcohol. 

His clothing should be sufficiently warm and by all means light. 
Thin, fine wool gives most satisfaction; the garments must be 
made sufficiently large to permit free movement, and while the 
whole body should be covered, there is no reason for elongating 
the skirts to the extreme length that is fashionable. The little 
shirts and skirts should be closed by means of tapes rather than 
pins or buttons, and suspended garments must be hung from the 
shoulders. Diapers are best made from linen diapering ; but if 
this is objected to on the score of expense a cotton substitute 
may take its place. The abdominal band is not so necessary as 
mothers usually believe. There is a reason for it during the 
first two months when a pad over the navel may be required to 
prevent a possible hernia, but after that time it is not of much 
value. From the first days the feet should be covered with 
woollen ''booties." 

The daily bath for the first few weeks should have the tern- 



26 THE MEDICAL DISEASES OF CHILDHOOD 

perature of the body ; as the child increases in strength and vigor 
the warmth of the water may be lessened, so that at the end of 
the first year it is no more than from 30° to 33° C. (86° to 91.4°F.). 
When the child is old enough to stand up with security, it is a good 
plan to follow the ordinary warm bath with a rapid douche whose 
temperature is a few degrees lower. Another good plan is to 
give the cool douche in the morning, the child standing in a few 
inches of warm water, and follow it with a brisk but not too vio- 
lent rubbing. The warm bath may then be reserved for the even- 
ing before the child retires. If the child does not react properly 
after the cool douche, it should be discontinued. Young children, 
before being clothed, may be powdered in all the folds of the 
body with some bland dusting powder to avoid irritations of the 
skin to which they- are peculiarly liable ; if the diapers are not 
thoroughly clean and dry when they are put on, if the soap used 
in the bath and laundry is harsh, or if the little one's gastro- 
intestinal system is deranged, the likelihood of these irritations is 
always imminent and their results are sometimes serious. 

The principal business of a new-born baby is to nurse and 
sleep. In the period immediately after birth he should devote 
nearly nine-tenths of the day to the latter, and every disturbing 
factor must be removed. The best position for sleep is lying 
somewhat on the side, and he should be changed from right to 
left and left to right in order to avoid a one-sided pressure. He 
should, as far as possible, sleep in the dark, the room must be 
reasonably quiet, thoroughly well ventilated, not draughty, and 
of a reasonably large size. The night-gown may be made of some 
light, fine woollen stuff, and after the first months, and in cool 
weather should be of the so-called union form with the legs con- 
tinued so as to form stockings. The coverings should be warm 
but light blankets, and for very young or delicate children a hot 
water bag placed at the feet is a desirable precaution against 
chilling. With increasing age less time will be passed in sleep ; 
in the second three months he will be awake about six or seven 
hours in the twenty-four, in the third from seven to eight, and 
at one year he will sleep about eleven or twelve hours at night 
and two during the day. The daily nap, beginning at noon, 
should be insisted on, until the child is four or five years of age. 

Good habits of sleep are easily inculcated provided there is 
some definite system observed. Artificial " comforters," rubber 



GENERAL HYGIENE OF THE NEW-BORN CHILD 27 

nipples and similar articles for the child to suck on should not be 
used ; singing and rocking the baby to sleep are no more than 
useless forms of infantile tyranny for which there is rarely any 
excuse. If the child is not sick, if he is nursed regularly during 
the day, being roused from a nap whenever the fixed nursing 
time comes, it will not be a difficult matter to put him asleep 
promptly. But there is a period when sleep must be insisted 
upon, when no nursing should be allowed, when quiet must reign 
in the house not only for the child's sake but also for the mother's. 
This time is from midnight to six in the morning during the first 
two months, eleven to six during the next two, ten to six during 
the fifth and six months and from ten to seven in the succeeding 
period. 

An infant who is well trained in habits of sleep is not only 
healthier and more amiable than he otherwise would be, but also 
he is more amenable to other forms of discipline. One of the 
most important of these is the early formation of habits of 
cleanliness. He can be taught to control urination and defalca- 
tion at a surprisingly early age, within a few months commonly, 
with the natural result of decreasing the work of caring for him, 
of promoting the efficient action of the gastro-intestinal track and 
lessening the liability of skin diseases. It is no difficult matter 
to place him on the chamber vessel at regular intervals and sup- 
port him there for a reasonable time ; and within a few days or 
weeks one will undoubtedly begin to see the salutary effects of the 
procedure. 

Outside of the exercise which an infant derives from the un- 
restrained movements of arms and legs, a very important matter 
is the regularity as well as the sufficiency of being carried into 
the open air. In warm weather this may be begun within a week 
or ten days after birth. In winter it is usual to wait until he is 
a month old ; but the delay should not be longer unless he is 
premature, extremely weak, or the weather is particularly rough 
and inclement. Clear cold weather is no bar, for he can easily 
be made and kept so comfortably warm that it will act as an 
exhilarating tonic. The length of the airing should be increased 
from a few minutes at the first outing until, weather permitting, 
hours are to be spent out of doors. He may be allowed to sleep 
during these outings whether the temperature is high or low. 

The nursery should be one of the largest, lightest, and airiest 



28 THE MEDICAL DISEASES OF CHILDHOOD 

rooms in the house, preferably one with a southern exposure. Its 
furniture should be of wood and not textile-covered. There 
should be no heavy curtains or portieres, and its walls should be 
painted or covered with a glazed paper which permits washing. 
The best sort of floor is of hard or painted wood covered in part 
by rugs that are not too large to permit of frequent removals and 
cleansing. Provision for thorough and constant ventilation, ex- 
cepting in the very coldest weather, should be made in the windows 
without allowing the formation of draughts. The best method of 
heating is a coal or wood fire which at the same time insures a 
fair exchange of air. 

One of the most important matters in the care of a child is the 
selection of a nurse ; and the physician can do the child and the 
family no greater service than to secure the engagement of an in- 
telligent and faithful person. The usual custom of engaging an 
uninformed and careless peasant, whose habits, lack of discipline, 
and general inaptitude smack of the fields and the hovel, is most 
illogical and mischievous. No woman would think of putting in 
the hands of such a maid the full custody of jewels, fine orna- 
ments, clothing, or furniture ; but the responsibility of a child is 
evidently thought to be of less importance. To the thinking mind 
the elaboration of such an error is unnecessary. It is likewise 
unnecessary to demonstrate that more advantage can be obtained 
from being lavish in the way of hiring the best and most intelli- 
gent attendants for a child than from putting an equal outlay on 
the child's clothes and toys. 

A final recommendation should be made to inspect and cleanse 
the male genital organs, especially the glans penis. If adhesions 
exist they must be broken up, and under no circumstances ought 
smegma be allowed to accumulate. If the foreskin is too long and 
too tight, it should be amputated. 

The whole care of an infant calls for the exercise of thought- 
fulness, common-sense, and the exercise of those well-known prin- 
ciples of sanitation which constitute the foundation of health. 
There is nothing peculiarly mysterious about it, nothing that can- 
not be logically deduced from the recognition of plain facts which 
an observing eye can see without difficulty. 



/ I 



CHAPTER III 
METHOD OF EXAMINATION AND DIAGNOSTIC SUGGESTIONS 

Therapeutic Suggestions 

The physician on entering the sick-room must remember that 
the patient is very young, lacking in self-control, irritated, and 
exhausted by illness and pain, easily alarmed, and even more ir- 
rational than adult patients. He must try to avoid any clash, any 
abruptness or harshness, any appearance of severity or impatience. 
It is often the best plan to begin talking with the mother or nurse, 
to sit for a few moments without noticing the child at all, in order 
to give the easily alarmed little mind an opportunity to become 
familiar with the stranger. Then the story of the sickness should 
be elicited from the mother as thoroughly as possible : how it be- 
gan, the order of development of the symptoms, the previous his- 
tory of the child from birth, the existence of similar cases in the 
family or neighborhood, the tendency of the family toward one 
disease or another, and finally, the full story of the child's pres- 
ent condition, including an account of the methods of feeding, 
dressing, sleeping, and exercise. By this time the child in all like- 
lihood will have become used to the stranger's presence, and the 
physical examination may then be made. The patient should be 
entirely undressed and his body narrowly inspected. The amount 
of information to be obtained depends upon the physician's power 
of observation. No rules can entirely govern this, for they cannot 
create a keen eye, nor an experienced faculty of interrogation ; 
nevertheless, a systematized method is always useful, and gives 
definite instead of desultory results. The posture will first en- 
gage the attention, and the condition of the joints, back, chest, 
and extremities must be noticed. One must examine the skin, its 
hue, whether it is dry and hot, or wet with perspiration, the cir- 
culation in the extremities, the color of the conjunctivae, the 
condition of the cornea and pupil, the facial expression and its 
character, whether it denotes apathy, restlessness, or pain. Fright 

29 



30 THE MEDICAL DISEASES OF CHILDHOOD 

is what one most commonly sees, and it is in sharp contrast to the 
apathy of marked prostration or mental disease. An expression 
of pain will commonly be seen in examining a case of pleurisy, 
rheumatism, scurvy, rickets, injury, and general hyperesthesia in 
meningitis. Mention should be made of the general tenderness 
that so frequently comes with auto-infections from the gastro- 
intestinal canal.. 

The respiration may show various conditions : it may be 
slow or rapid, shallow or dyspnceic (on inspiration or expira- 
tion, or both), regular or irregular ; it may be impeded by 
disease of the nose, by hypertrophy of the pharyngeal tonsil, by 
disease of the throat, larynx, and lungs. The observation of 
the pulse is always important, and its character is more notewor- 
thy than its rapidity. One should notice its rate, regularity, and 
tension. The slow and irregular rate of meningitis is sufficiently 
peculiar to deserve mention. In this connection one may men- 
tion the item of temperature. In infants the thermometer should 
always be inserted in the rectum, thereby often obtaining a read- 
ing that is slightly more than 37° C. (98.6° F.). In very young 
infants the normal mark may be as high as 37.5° C. (99.5° F.), 
and in conditions of prostration a subnormal temperature is of 
frequent occurrence. As a general rule, however, pathological 
conditions in children give higher temperatures than in adults, 
the exceptions — as in enteric fever — being very few. Indeed, 
it is no unusual thing to encounter very high ranges from seem- 
ingly trivial causes ; thus a simple pharyngitis, rhinitis, or a 
slight functional disorder of the stomach may be associated with 
a really great production of fever. Doubtless the marked sus- 
ceptibility to low grades of intoxication due to bacterial products 
may be the responsible agent. 

The cry may at times be partially diagnostic. That produced 
by temper is much less often seen than common belief implies. 
In young infants it is practically non-existent, and in older chil- 
dren it is, as a rule, provoked and encouraged by an unreasoning 
and flagging discipline. A child that is constantly petted, coaxed, 
and cajoled, cannot be expected to have a good disposition ; and 
if he has, it is in spite not on account of such treatment. If he 
has been accustomed to rocking, to sucking on an empty rubber 
nipple, to being trotted up and down, to the exaggerated grimaces 
of the attendants which are designed to amuse him, he naturally 



EXAMINATION AND DIAGNOSIS 31 

will demand the continuance of such attentions in an increasing 
variety. When he cries, it will be violently, in a prolonged 
fashion, with a throwing out of the extremities, stiffening of the 
body, and sometimes holding of the breath. The cry of hunger 
is a sharp, fretful cry, often accompanied by sucking of the fingers 
and an inconsiderable rise of temperature. It is stilled by feed- 
ing. The cry of gastric derangement is fretful, irregular, com- 
plaining ; it becomes quiet when the child is fed, but soon returns. 
It is accompanied by other signs of impeded function that makes 
a diagnosis comparatively simple. 

A child with colic and abdominal disorders gives a sharp, loud, 
and frightened cry, that often may be described as a scream ; it 
comes in gusts and paroxysms, permitting him to sleep only for 
short and scattered intervals. When the pain comes on, he 
clenches his fists, draws up the legs, hardens the belly, and the 
face often assumes a strained, bluish appearance. The cry due 
to pain, such as that caused by a pin, a scratch, a tight band, or 
offensive button, varies with the severity of the injury and the 
persistence of the cause. When the baby is exhausted his voice 
becomes weak, mildly complaining, whimpering. In otitis the 
cry is sharp, shrill, and cutting, and is commonly accompanied 
by a motion of the hand to the affected side of the head. In 
syphilis it is a snuffling, hoarse sound : in pneumonia it is quick 
and short, suggesting the sound of choking, and is associated with 
the rapid, impeded respiration ; in chronic tubercular meningitis, 
we hear the keen nocturnal note, and in marasmus there is a low, 
exhausted, attenuated moan or whine. Inspection will be com- 
pleted when we have examined the nose, head, genital organs, 
glands, and finally the throat. 

Auscultation of the chest is an exceedingly important factor. 
After noting the appearance, symmetry, and development of the 
chest, the lungs may be examined with a stethoscope rather than 
the naked ear. The posterior surface of the chest, on account 
of the closer proximity of the lungs, will give the plainer sounds. 
The so-called puerile breathing is harsher and louder than the 
adult form, partly on account of the comparatively large amount 
of bronchial surface, partly because the chest walls are thin ; this 
is especially apparent between the scapulas and under the clavi- 
cles. The small size of the air vesicles is apt to make a com- 
paratively slight congestion give the same interference with the 



32 THE MEDICAL DISEASES OF CHILDHOOD 

respiration that consolidation does in the adult. And when one 
portion is affected there is always a strong likelihood of some 
degree of compensatory emphysema in a neighboring part. An- 
other frequent source of error is the liability to pass over a small 
area of consolidation whose presence may be masked by the exist- 
ence of such a transitory patch of emphysema as that referred 
to. Percussion shows some peculiarities in the way of a cracked- 
pot sound over a normal but superficial bronchus, the hyper-reson- 
ant note over comparatively unaffected portions of lung tissue, 
and the ease with which the flatness due to a small amount of 
fluid may be overlooked. Fremitus due to bronchial irritation 
is very easily detected. 

In auscultating the heart, one should keep in mind the com- 
paratively large size of the organ in infancy, and its liability to slight 
irregularities of action. The murmurs in children under two and 
two and a half years of age are almost always congenital in origin, 
and the haemic murmurs are much more likely of occurrence in 
young children than those of organic disease. 

In the abdomen one notices the possible existence of fluid, 
tympanites, enlarged glands, local or general tenderness, and the 
retraction of the walls which occur in meningitis. The spleen is 
not easily made out by the palpating fingers unless it is enlarged, 
as in typhoid fever, malaria, or tuberculosis, syphilis, anaemia, and 
leukaemia. The liver, or rather its lower border, is much more 
readily distinguished below the free margin of the ribs, and any 
enlargement is more apt to deceive by its large than its small size. 

The possibility of involvement of the kidneys, especially as a 
complicating feature in the acute infectious fevers, is much greater 
than is usually thought ; and if proper attention is given to them 
the recoveries from these disorders will be quicker and more un- 
eventful than otherwise. It is therefore especially desirable to 
examine the urine as a routine procedure and with sufficient fre- 
quency. In infants there may be some difficulty in collecting it 
without an admixture of faeces. This can be avoided in the male 
by tying a condom over the head of the penis, and in the female 
by fastening a small cup or similar receptacle over the vulva and 
inside the napkin. Concentrated urine and crystalline uric acid 
produce brownish yellow stains on the diaper. 

Young children excrete a larger quantity of urine, compara- 
tively, than do adults. This is partly due to the character of 



EXAMINATION AND DIAGNOSIS 



33 



their food, and in part to their active tissue-change. Many 
authors have given tables of approximate amounts per day, and 
the average of these, as stated by Holt, are the following : — 



Age 


Grammes 


Ounces 


First twenty-four hours 

Second twenty-four hours 

Three to six days 


Oto 60 

10 to 90 

90 to 250 

150 to 400 

210 to 500 

250 to 600 

500 to 800 

600 to 1000 

1000 to 1500 


Oto 2 
ito 3 
3 to 8 


Seven days to two months 

Two to six months 

Six months to two years 

Two to five years 


5 to 13 

7 to 16 

8 to 20 
16 to 26 


Five to eight years 


20 to 40 


Eight to fourteen years 


32 to 48 



In the first period of life it has in some cases characteristics 
which are noteworthy. The proportion of uric acid is higher 
than at any other period during a state of health, its specific 
gravity is low, the acidity is marked, it sometimes has small 
amounts of sugar, albumin, hyalin, and granular casts. After 
the passage of a few months, these seemingly abnormal characters 
gradually fade away. 

Glycosuria 

In children who are being wrongly fed, especially if their food 
contains too much sugar, the urine may contain a sugar deriva- 
tive that is readily detected by Fehling's test. A somewhat 
similar phenomenon has shown itself after attacks of acute sick- 
ness. The pathological significance is not great, for with the 
regulation of the diet and general health, the urine becomes 
normal. 

Anuria 

In infants who are quite healthy there may be a sudden and 
seemingly causeless arrest of urinary excretion. The cause is 
supposed to be nervous and has never been satisfactorily ex- 
plained. It may continue for a half day, a day, or even longer. 
It is removed by warm baths, by the drinking of fairly large 
amounts of water, and by the application of heat to the lumbar 
region. It is rarely, if ever, necessary to prescribe the ordinary 
medicinal diuretics. 



34 THE MEDICAL DISEASES OF CHILDHOOD 

Polyuria 

An opposite condition is seen, in rare cases, among older chil- 
dren. Its cause has never been ascertained ; but the noteworthy 
observation has been made that in many instances it follows 
injury or disease of the brain and spinal cord, and may occur 
in the convalescence of the acute fevers. The main symptoms 
are polyuria and polydipsia, nervous and vaso-motor disturbances, 
and at times some degree of malnutrition, anaemia, and disordered 
development. 

The treatment is directed toward the improvement of the 
general health and strength by means of a carefully regulated 
diet, mode of life, exercise, clothing, and rest. General tonics 
are to be administered, and the amount of fluid consumed is to 
be restricted to a reasonable amount. 

The condition is easily distinguished from diabetes mellitus 
by the lack of sugar in the urine. While it is not so dangerous 
as the latter disease, it nevertheless in many cases is incurable 
and sometimes has a fatal termination. 

Indican is occasionally present in the urine when the patient 
is suffering from intestinal putrefaction and the lack of proteid 
digestion. It is thus seen in acute and chronic derangements of 
the intestines and the conditions with which such derangements 
are concomitant factors, as in chronic constipation, convalescence 
after the acute fevers, epilepsy, and convulsions. 

Acetone and diacetic acid have been found in large amounts in 
the urine of children who were suffering from the acute diseases 
with high fever, and in certain nervous conditions. 1 They are 
formed by disturbed metabolism and disappear when the ordinary 
healthy condition returns. Comparatively little is known about 
them, and the amount of our information does not justify elabora- 
tion of the subject. Small quantities of both indican and acetone 
have been found in the urine of healthy children. 

Hematuria, pyuria, lithuria, and functional albuminuria occur 
in children but rarely ; and when they do, the causes and manifesta- 
tions are the same as in adults. Thus, one may occasionally see a 
post-febrile albuminuria which generally fades away on the re- 
appearance of health. Hemoglobinuria is described in another 
place. 

1 For fuller statements concerning these conditions the reader is referred to the 
researches of Herter, of New York. 



■ 



EXAMINATION AND DIAGNOSIS 35 

Therapeutic Suggestions 

The practitioner should always keep the fact in mind that 
children, while they easily fall into abnormal and pathological 
conditions, react with comparative ease and rapidity to drugs, effi- 
cient nursing, and advantageous environment. He must, accord- 
ingly, be exceedingly careful about every item of treatment, must 
make his orders as simple and direct as possible, and must never 
allow himself the privilege of prescribing measures whose effi- 
ciency has not been fairly well demonstrated by experience or 
reason. There is little excuse for the " shot-gun " prescription in 
the treatment of adults, but there is absolutely none in that of 
children. 

One of the main indications in the care of these little patients 
is the promotion of excretory functions. If the attendant will 
see to it that the gastro-intestinal canal, the urinary system, the 
glandular system, and the skin are in active and tonic state of 
efficiency, he will have accomplished a considerable measure of 
the help that we can give toward eliminating disease. This meas- 
ure is yet further increased when the food has been so selected 
and modified that excretion, digestion, and assimilation are rea- 
sonably and actively conserved. With these items attended to, 
the amount of prescribing of drugs is remarkably small. Of the 
medicines that remain, the principal part is composed of tonics, in 
the discriminating use of which the physician has ample oppor- 
tunity to show judgment and resourcefulness. 

There are some drugs that should rarely be prescribed for 
children. The main ones are opium and its derivatives, the coal- 
tar antipyretics, and the more potent depressants. Naturally 
enough there are circumstances where they must be used ; but 
the quantities must always be as small as will do the desired 
work, and at the same time one should try as far as possible to 
counteract their possibly bad effect. For instance, it may be neces- 
sary to prescribe fairly large doses of antipyrin in whooping 
cough, but a heart stimulant must, at the same time, be given in 
order to avoid collapse ; opium may, in rare cases of great pain, 
as, for instance, in acute rheumatism or peritonitis, be required ; 
then it may be prescribed in the form of deodorated tincture, in 
Dover's powder, or in the alkaloid, morphine. Under all circum- 
stances, however, one must remember that it disorders the gastro- 



■■■^■■^^ 



36 THE MEDICAL DISEASES OF CHILDHOOD 

intestinal track, that it temporarily abolishes secretions, and that 
in many cases its use will prolong the original disease, or delay 
convalescence. In the cough mixtures for the older children, its 
place is often well taken by codeine, whose bad effects are much 
less pronounced. In the younger ones the use of bromide of 
soda is always much safer. Of all the bromides this one seems 
to be most easily borne, it has the least irritating effect upon the 
kidneys and heart, and the doses may with safety be made fairly 
large. 

Of the other antispasmodics, belladonna will be found to be 
reasonably safe ; and in some cases it is not only efficacious, but 
also can be tolerated in remarkably large doses. This is especially 
noticeable in the functional enuresis of children, where its value 
becomes apparent only when the amount prescribed is large. A 
slightly related drug that is comparatively well borne is chloral, 
which is commonly given by rectum in order to avoid the irrita- 
tion which it so often produces on the stomach. 

In the last few years the use of antipyrin in the convulsive or 
spasmodic diseases of children has been increasing. At first the 
step was taken with hesitancy, but cautiousness has now given 
way to a bolder confidence, for remarkably few cases of its ill 
effects have come to notice. I have used this drug for the past 
four years in a wide variety of circumstances, and in compara- 
tively large doses, but always with a cardiac stimulant. It has 
so often given me satisfaction that I take pleasure in stating 
that I have never had a case of collapse which I could attribute 
to it. 

In prescribing for a child one cannot be guided exactly by his 
age ; and for this reason it is unwise to give or follow any hard 
and fast scheme of fractional amounts of the adult dose. In chil- 
dren much more than in adults it is necessary to reckon with the 
size, weight, susceptibility, and vigor of the patient ; and there- 
fore each one must receive his special doses. This cannot possibly 
be laid down in a book ; but the practitioner, by a careful knowl- 
edge of the means at his command and an equally careful summing 
up of the physical factors of his patient, will be able, at the expense 
of not much trouble, to settle the matter of each individual case. 

To summarize, we may say that children do not bear well such 
drugs as opium, the inorganic preparations of iron, most of the 
coal-tar products, the corrosive acids, large doses of quinine, 



EXAMINATION AND DIAGNOSIS 37 

cocaine, iodoform, alcohol in large doses, and the salicylates. 
They tolerate well such preparations as the various salts of mer- 
cury, the bromides, especially the bromide of sodium, the iodides, 
moderate doses of chloral, and fairly large doses of antipyrin. 
Concerning alcohol there is a wide difference of opinion ; one is 
safe, however, in prescribing it during times of pyrexia in small 
although frequent doses. 

There are two methods of external treatment that may well be 
eliminated : blisters and poultices. The first is altogether too 
irritating, and often will produce a disorder that is worse than 
the one which it is intended to help. Its place is well taken by 
the simple, clean, and cheap mustard leaves that are sold in every 
drug shop. These leaves are usually superior to the mustard 
poultices or pastes that formerly were in such extensive use. 
Poultices likewise may be advantageously abolished, for they are 
apt to do harm by their weight, their sogginess, their lack of 
asepsis, and the ease with which they are chilled. In place of 
them one may use aseptic or antiseptic moist dressings made 
of clean gauze or similar material, wrung out of hot water, bo- 
racic solutions, or turpentine mixtures, and covered by rubber 
tissue. This method is clean, not troublesome, retains the heat, 
and is easily prepared. 

The use of hydrotherapy is especially to be commended for 
children. And every physician who has occasion to treat them 
should make himself thoroughly familiar with the various methods 
employed. 



CHAPTER IV 
CONGENITAL MALFORMATIONS AND DEFORMITIES 

The Brain 

Cyclopia is the name given to that condition of the brain in 
which there is no separation into two hemispheres. With it are 
other deformities, snch as a single ventricle and usually a single 
eye. This eye is located at that part of the face where the root 
of the orbit ought to be. In other cases there may be two eyes, 
joined or separate, or no eye at all. There may be two, one, or 
no optic nerve. Various parts of the bones about the nose or 
orbits may be lacking, or only present in part. 

Anencephalia denotes a partial or total lack of brain. In some 
cases there is likewise acrania, or absence of the skull bones 
excepting those at the base. The scalp may completely or only 
partially cover the open space. 

Cephalocele, or hernia of the brain, designates a protrusion of a 
part of the brain, covered with membranes, through an abnormal 
opening of the skull. The brain may otherwise be normal or in 
the condition of anencephalia. If the sac consists of membranes 
alone, it is called meningocele ; if it is filled with fluid, it is called 
hydromeningocele ; if it contains both brain substance and fluid, 
it is called hydrencephalocele. Such sacs may be of various sizes 
and in various situations. 

Microcephalia denotes a small-sized brain in a small skull. 
The condition may sometimes occur from inflammation and 
disease of the foetal brain. In some cases parts of the brain may 
be absent, but the mental condition good. In other cases the 
whole brain is small and rudimentary, the least development being 
in the cerebral hemispheres. The convolutions may be rudi- 
mentary and the cavities filled with serum. 

Porencephalia is the name of a deformity which consists of a 
circumscribed and sharply defined absence of tissue in the brain. 
The hole may be very small or large, shallow or deep. It occurs 

38 



CONGENITAL MALFORMATIONS AND DEFORMITIES 39 

congenitally, or may be acquired ; in the latter case it commonly 
results from meningeal hemorrhage. 

The Spinal Cord 

The spinal cord may be entirely absent, a condition called 
amyelia; such cases commonly occur in conjunction with anen- 
cephalia. When the cord does not exist at all its place may be 
taken by a cord or sac of connective tissue which may contain 
fluid. In other cases it may exist in part (atelomyelia), in still 
others it may be longer than the normal. Very rarely it is 
double (diplomyelia), either in parts or through its whole length. 
An abnormal position of gray matter may exist, and constitutes 
what is known as heteropia. 

Hydromyelia is a condition of the cord in which the central 
canal is dilated by an unusually large amount of fluid. The force 
of gravity, by regulating the amount of pressure, decides the 
degree of dilatation and at the same time the intensity of the 
atrophic process. Hydromyelia externa, or hydrorrachis externa, 
is a variant of the form above in which the fluid is contained 
between the spinal meninges ; the logical result is an atrophy of 
the cord due to pressure. 

Spina bifida, or hydromyelocele, is a hydromyelia plus a smaller 
or greater opening of the posterior aspect of the spinal canal; 
there may be an anterior opening, and the condition would then 
be called spina bifida occulta — a very rare deformity. Of hydro- 
myelocele there are three varieties which we commonly recognize : 
meningocele, meningo-myelocele, and syringo-myelocele. 

In meningocele there is usually a small aperture leading to the 
central canal, often situated in the cervical region. The tumor 
consists of membranes filled with fluid, and may be of variable 
size. It is covered with a strong, normal skin, and on account of 
its protection as well as its simple composition offers a good chance 
of life or even recovery. 

Meningo-myelocele is a commoner and more dangerous form, 
its greater danger lying in the fact that instead of being entirely 
covered by a strong skin, its centre is protected by nothing more 
than a thin membrane, to which, or to a near-by part, the cord is 
attached. The fluid is derived from the anterior arachnoid or 
subarachnoid space, and produces a moderate-sized sessile tumor 



40 THE MEDICAL DISEASES OF CHILDHOOD 

that is oftenest situated in the lumbar or sacral regions. The 
thin and easily irritated membrane at the centre of its surface 
makes the danger of rupture, infection, and inflammation a con- 
stant and serious menace, and the presence of the cord in the sac 
renders operation exceedingly grave. 

Syringo-myelocele is the rarest and most deadly form of spina 
bifida. The tumor is usually in the lower part of the dorsal or 
the upper part of the lumbar region. The fluid is derived from 
the central space of the cord, and communicates with the lateral 
ventricles of the brain. The sac is lined with the crushed and 
degenerated spinal substance, and offers a direct and unimpeded 
way to the other parts of the cord and brain. This form com- 
monly occurs in association with hydrocephalus ; and with all 
varieties there may be deformities of the extremities, trunk, and 
face. 

The symptoms in spina bifida vary according to the situation 
and composition of the tumor. In meningocele they may be very 
few or none, and treatment may bring about a cure. In meningo- 
myelocele and syringo-myelocele there will be some form of paraly- 
sis and focal symptoms that vary with the portions of the cord 
which are involved. The weaker the covering of the sac is, the 
greater is the danger of irritation, rupture, draining away of cere- 
brospinal fluid, and infection of the cord and brain. 

The treatment is purely surgical and should not be conducted 
by the general practitioner. From the very beginning the tumor 
must be protected by a pneumatic rubber ring from pressure, 
irritation, and blows, thereby avoiding the dangers of rupture and 
infection. The older methods of aspiration, with or without 
injection of fluids which promote an adhesive inflammation, are 
gradually giving way to radical operations which seek to remove 
the defect in a logical and scientific manner. The meningocele 
gives the best hopes for recovery, the syringo-myelocele the 
poorest. 

The Larynx and Trachea 

Both larynx and trachea may be wanting in acephalic beings, 
or in other cases they may be unnaturally small or large. In still 
other instances there is an opening between the trachea and the 
oesophagus. In some children one or more of the cartilages may 
be small or absent, the epiglottis in especial being subject to vari- 



CONGENITAL MALFORMATIONS AND DEFORMITIES 41 

ations according to which it is too large or too small. Or the 
trachea may have too small or too large a number of rings, or may 
divide into three instead of two bronchi ; in the latter case, two 
lead off to the right and one to the left lung. There may be 
faulty development of the branchial arches, with the resulting pro- 
duction of fistula? which communicate with the trachea or pharynx. 
In some instances the trachea instead of being in front of the 
oesophagus has been found behind or to the left side of it. 

The Luxgs 

Cases of partial or complete absence of one or both lungs have 
been reported. A deformity, which is tantamount to partial ab- 
sence, has occurred : it consists of a vicious development of pul- 
monary tissue into small bags or sacs which contain air and serum. 
These sacs communicate with the bronchi. In other cases the 
lobes may be subdivided ; and a case of supernumerary lobe has 
been reported. Transposition of the lungs, with similar relational 
changes of the heart and abdominal viscera, may occur. And, 
finally, in the absence of a part of the chest wall, a hernia of the 
lung may occur. 

The Heart 

Monsters have been born in whom there was no heart at all, 
but they are very rare. Cases of two hearts in one bod}' have 
been known ; the instances of a large-sized heart from obstructive 
malformations of the great vessels are more frequent. Also, a 
very small-sized heart may occur, usually associated with small 
and thin arteries ; such anomalies generally appear in anaemic and 
haeniorrhagic patients. Unnatural shapes, relations between the 
different parts, and positions have been noted ; one side, or a part 
thereof, may be over-developed, while the other is hypoplastic ; 
the heart may be transposed from the left to the right side with 
corresponding changes in its relations ; in the absence of a part 
of the chest wall the heart may project outside and then usually 
lacks its pericardium. Or the diaphragm may be partly or wholly 
absent, so that the heart lies in the abdominal cavity. In badly 
deformed monsters the heart may be in the neck or even in the 
head. 

One or more parts of the heart or its great vessels may be mal- 
formed or deficient in various ways. The trunk, from which the 






42 THE MEDICAL DISEASES OF CHILDHOOD 

aorta and pulmonary artery usually spring, may be so developed 
that the division into these two branches exists only partially or 
not at all. At the same time the septa between any two of the 
four cavities may be deficient : thus there may be one ventricle 
and two auricles, or one ventricle and one auricle, or one ventricle 
and no auricle at all. 

In other cases the trunk of the aorta or pulmonary artery is 
absent, obliterated, or stenosed. As a result, the septa between 
the cavities and the course of the blood current are abnormal. 
Thus the aorta at any part of its course is obliterated or very 
much narrowed. Then the pulmonary artery branches off from 
the descending aorta, supplying the subclavian and carotid arte- 
ries. To complete the circulation, the foramen ovale is patent or 
there is no inter-auricular septum ; this condition may be supple- 
mented by an imperfect or absent inter-ventricular septum, and 
finally the force of the blood stream results in hypertrophy of the 
right ventricle. In other instances, the pulmonary artery, instead 
of the aorta, is obliterated, defective, or stenotic. Its branches 
then are supplied through the ductus arteriosus by the aorta. 
The inter-ventricular or inter-auricular septum is imperfect and 
the foramen ovale is patent. 

There is another class where the malformations are farther 
removed from the heart. Thus, the aorta may be very small and 
narrow at the ductus arteriosus, or between that point and the 
left subclavian, or all the branches of the aorta may spring from the 
arch ; then the descending aorta would be continued from the pul- 
monary artery. Other abnormalities are transpositions of the 
arteries and veins, with or without imperfections of the septa. 

A commoner set of malformations consists of deficiencies of the 
septa alone. The foramen ovale, or the ductus arteriosus may be 
patent or there may be an aperture in the ventricular septum. 
Or one of the auriculo-ventricular apertures may be closed while 
communication may be kept up through the foramen ovale, and 
an imperfect septum between the ventricles. 

Another interesting condition consists where one or more of 
the cardiac openings are defective or do not exist. Or the valves 
of the aortic or pulmonary orifices may be changed from three to 
two or four, or the semilunar valves are fenestrated. 

The most general symptoms of such organic malformations of 
the heart as permit life are cyanosis induced by interference with 



CONGENITAL MALFORMATIONS AND DEFORMITIES 43 

pulmonary circulation, cardiac murmurs, clubbing of the distal 
phalanges of the fingers, dyspnoea, episaxis, haemoptysis and oedema 
of the feet and dropsy of the serous cavities. In the large major- 
ity of cases the predominant signs are the conjunction of a mur- 
mur with cyanosis ; to ascertain the location of the disorder is not 
by any means an easy matter. There are, however, a few generali- 
zations which may be worth mentioning, even though they do not 
help the treatment of the case. Thus, the common condition of 
a systolic murmur heard at the base and combined with cyanosis 
usually denotes a stenosis of the pulmonary artery with or without 
abnormalities of the septa. A systolic murmur heard at the base 
but without accompanying cj^anosis commonly denotes a defective 
ventricular septum. A systolic murmur at the apex may be asso- 
ciated with a deficient auricular septum, open ductus arteriosus, 
and transposition of the great vessels ; a patent foramen ovale may 
give a presystolic and pulmonary insufficiency a diastolic murmur. 
On the other hand there may be aortic or pulmonary stenosis, defi- 
cient septa, transposition of the great vessels or irregular branching 
of them without either murmurs or cyanosis, or with cyanosis alone. 

There is no specific treatment for these conditions, and all that 
one can do is to treat the symptoms. One must therefore try 
to distinguish between congenital and acquired cardiac disease. 
The former is characterized by its occurrence, or discovery, at or 
near birth, its possibly atypical character, the absence of exciting 
causes in the history, the harsh quality of its sound and probable 
location at the base. ELernic murmurs may be distinguished by 
the facts of their being comparatively soft, being heard over the 
large vessels and in the neck ; and although they are systolic and 
heard at the base, nevertheless are not connected with the enlarged 
right heart which so commonly accompanies congenital disease. 
There are, in addition, the appearances and history of hseniic 
disorders. 

The outlook in congenital disease of the heart is not good ; the 
patient may live for one or more years, but the diseased condition 
or intercurrent sickness is apt to cause death before childhood has 
passed. Pulmonary disease is especially liable under these cir- 
cumstances to bring about a fatal result. But even if death does 
not immediately occur, the patient's vitality is not strong ; and, 
as a rule, the problem of caring for these cases in an efficient 
manner is complex. 






44 THE MEDICAL DISEASES OF CHILDHOOD 



The Mouth 

The congenital malformations of the mouth are the result of 
arrested development ; all the parts may be present but in an 
abnormal condition, or many of them may be absent. Thus the 
whole lower part of the face below the temporal bones may be ab- 
sent, and these bones may approach each other in the median line. 
Cases have occurred in which the mouth is closed from behind, 
and nothing remains but the opening between the lips ; in others 
the lips are joined completely or so much that only a small round 
aperture exists. In some instances there is a large irregular cavity 
which includes the location and openings of the mouth and nose 
and even the orbits as well. Minor malformations may exist, such 
as imperfectly formed lips, prolongation of the mouth so that it 
extends almost to the ears, cleft lower lip and undersized lower or 
upper jaw. The commonest deformity is the so-called hare-lip, 
a cleft in the upper lip situated under the middle of the nostril, 
which may exist on one or both sides ; it may be so slight as to 
form no more than an indentation, or so marked as to divide the 
lip completely. It is commonly accompanied by single or double 
cleft palate. This consists in a fissure of various size in the soft 
or hard palate. The soft palate is more frequently so affected 
than the hard, and the resulting deformity is naturally less serious. 
With both hare-lip and cleft palate the child may be unable to 
nurse in a normal manner, and requires feeding with a spoon or 
a large medicine dropper. These children may give much trouble 
in the attempt to maintain their nutrition, and on account of their 
feeble vitality contract many intercurrent diseases that have a 
more serious prognosis than in perfectly formed children. The 
deformity of the lip should be corrected as soon as the physical 
condition of the child permits, while that of the palate should 
usually be postponed until the age of two or three years. 

The tongue may be deformed in the way of a hypoplasia or 
hyperplasia, a true microglossia or macroglossia ; and rare 
instances of bifid tongue have been reported. The anterior 
part may be entirely absent, or the whole tongue may be adher- 
ent at the bottom, sides, or top to corresponding parts of the 
mouth. The frenum of the tongue may be so much shortened 
that full movement and functional activity of the organ may be 
impeded. In other cases it may extend to the tip of the tongue. 



CONGENITAL MALFORMATIONS AND DEFORMITIES 45 

The deformity is easily rectified by snipping the membrane with 
a scissors. Another slight and unimportant malformation is 
bifid uvula. I have noticed in a number of cases the occurrence 
of this condition in the mother or father as well as in the child. 
No treatment is required. 

The (Esophagus 

The whole organ may be absent or may exist only in the 
lower half, the upper part being replaced by a fibrous cord. In 
some cases it may be irregularly dilated, may have diverticula, 
or may be divided in its upper half into two parts. 

Stomach 

In acephalous monsters the stomach may be entirely absent. 
More often it may be very small or very large, and it has been 
known to possess a median constriction that practically divides 
it into two parts. More commonly the pyloric orifice is much 
decreased in size, and it has been known to be closed. The whole 
viscus may be forced through a diaphragmatic hernia, or on account 
of absence of the thoracic wall may be on the exterior of the body. 
It may be transposed in all its relations in those cases where gen- 
eral visceral transportation exists. It has been found to be adher- 
ent to some part of the small intestine, and occasionally its foetal 
upright position remains unchanged. 

The Ixtestixes 

The intestines may be abnormally short or long ; in the small 
intestines there may be various degrees of stenosis, or there may 
be blind terminations. There may be diverticula of the intes- 
tines in various positions. The most common is where the 
process is attached by one end only to the convex surface of the 
gut or its attached border, in the latter case being attached to 
the mesentery by a band of peritoneum. Such a process is usu- 
ally from two to ten centimetres in length, and smallest at its free 
extremity. Sometimes there may be a diverticulum of the ileum, 
which is attached by a fibrous cord to the umbilicus. Such a one 
may be the remains of the omphalo-mesenteric duct, and is com- 
monly called Meckel's diverticulum. Occasionally it remains 
patent throughout its whole length, thus producing a fsecal 
fistula ; at other times a part of its mucous membrane may be 



46 THE MEDICAL DISEASES OF CHILDHOOD 

extruded and form an umbilical or diverticulum tumor. Another 
variety of diverticulum consists of a patency of the abdominal 
wall at the umbilicus, which is joined immediately to a similar 
opening in the ileum. The inferior parts of the ileum and colon 
are diminished in size or closed. A long diverticulum may, by 
catching a loop of intestine between its length and the abdomi- 
nal wall, produce an incarceration. 

The rectum or colon may be partially undeveloped ; the colon 
may be absent in part or wholly ; the rectum may be entirely 
absent, its lower half may be replaced by a fibrous cord or a blind 
pouch, or its anal extremity may be closed by a membrane. These 
various forms are called atresia ani. 

There may be a union of the rectum with the bladder and 
genital organs, so that a common outlet or cloaca is formed ; or 
the rectum may empty into the bladder, vagina, or urethra. The 
lower part of the rectum would then be absent. A very rare 
malformation consists of absence of the anterior abdominal wall, 
symphysis pubis, and anterior vesical wall ; the posterior vesical 
wall then receives the openings of the ileum, ureters, and vagina. 

The Peritonaeum 

The peritonaeum may be malformed in the way of arrest or 
excess of development. In the former there may be longitudinal 
lines of fissure near the median line; if the diaphragm is absent, 
the peritonaeum will be joined with the pleura; or the omentum 
or mesentery may be deficient in various areas. In other cases, 
there may be an excess of omentum, mesentery, or other process of 
the peritonaeum. If bands are thus formed, they may produce an 
incarceration of the intestine. 

The Liver 

The liver may be absent, its form may be changed, its lobes 
may be increased or decreased in number. The gall-bladder or 
ducts may be absent. The ductus choledochus may empty into 
the stomach or it may be double, one tube then emptying into 
the stomach and the other into the duodenum or both into the 
duodenum. The liver may be transposed to the left side or, on 
account of a diaphragmatic hernia, may lie in the thoracic cavity; 
absence of the abdominal wall may cause it to be on the exterior 
of the body. 



CONGENITAL MALFORMATIONS AND DEFORMITIES 47 

The Spleen 

The spleen may be absent, may be increased or decreased in 
size. It may be double, there may be small accessory spleens or 
it may be divided into lobes. In cases of transposition it may be 
found on the right side, in the thorax when there is a diaphrag- 
matic hernia, or outside the body when the anterior abdominal wall 
is lacking. 

Pancreas 

The organ may be wanting in monsters and in rare cases of 
marked umbilical hernia. Its duct may open into the stomach or 
the biliary duct, and sometimes it may be double. The head 
may be separated from the body of the organ and have its own 
separate duct. An accessory pancreas has been reported. 

The Suprarenal Capsules 
These organs may be absent in monsters ; there are, in addition 
seemingly normal cases of development in which they have not 
been found. Occasionally accessoiy bodies have been seen which 
grew from the surface of the organ and differed in no way from it 
in structural composition. The suprarenal capsule may be present 
and in correct position even if the kidney is absent. 

The Kidneys 

Both kidneys may be absent in monstrosities. One is lacking 
in a comparatively large number of cases; under such circum- 
stances, the remaining organ is larger than the normal. There 
may be no ureter on the affected side or the kidney may be re- 
placed by a small growth of fat and connective tissue from which 
a ureter leads to the bladder. Minor malformations may exist, 
such as disparity in the sizes of the two kidneys, double pelves or 
double ureters. In other cases the two organs may be somewhat 
more curved than usual and their extremities connected by a com- 
missure of fibrous or characteristic kidney tissue, the whole struc- 
ture imitating the shape of a horseshoe ; this peculiarity may be 
present at the top or the bottom. The structures may otherwise 
be normal or their ureters and vessels may be abnormally ar- 
ranged. Rare cases of blended kidney have been reported. The 
two organs may be bound together with a regular or irregular 
arrangement of the parts. They may lie on one side of the spinal 
column or in the pelvis. 



48 THE MEDICAL DISEASES OF CHILDHOOD 



The Urinary Bladder 

The bladder has been found lacking in a few cases ; oftener 
it is much smaller than the normal, and occasionally it is con- 
stricted in its middle horizontal plane, or divided in its middle 
vertical plane by a membrane. Sometimes the urachus remains 
patent if the urethra is congenitally occluded. In other cases 
the neck of the bladder is closed, or retention of small amounts 
of urine may occur on account of the existence of diverticula of 
the vesical wall. 

In a few instances the abdominal wall below the umbilicus 
has been absent, the whole pelvis is then lower and broader than 
the normal. In the opening the posterior wall of the bladder 
with the mouths of the ureters may be seen. In such circum- 
stances the genital organs are likewise malformed. In other 
deformities the bladder itself is normal, but is easily seen and 
touched on account of an opening in the abdominal wall. In yet 
other cases, there may be an opening in the bladder while all 
other organs are normal. 

The Urethra 

The urethra may be closed at any part of its length, the distal 
parts then being more or less completely undeveloped. In some 
cases it resists pressure so poorly that it almost immediately be- 
comes irregulately dilated ; also there may be valves in the canal 
that cause dilatation of it and the bladder. At times the opening 
may be irregularly placed, at the root of the penis or on the dor- 
sum ; the meatus on account of malposition of the whole tube 
may be in the inguinal region, or it may be double or triple. 
There has been a case reported in which the course of the urethra 
was paralleled by a tube on the dorsum of the penis and a meatus 
in the glans. 

The Vulva 

There may be an entire absence of the external genitals in 
the female ; or they may be partially formed, or wholly formed 
but not divided. The nymphse may be increased in size or num- 
ber ; the clitoris may be long — so much so as almost to resemble 
a small penis, it may be divided into two parts, or it may hold 
the meatus of the urethra. 



CONGENITAL MALFORMATIONS AND DEFORMITIES 49 

The hymen may show irregularities even when the other parts 
are normal. It may be entirely absent or imperforate. Instead 
of one perforation it may have several, or the perforation may be 
eccentrically situated. In other cases the free margin may be 
fringed or formed into small and irregular processes. 

The Vagina 

This organ may be entirely absent, especially when the other 
genital organs are wanting ; not so rarely it is present only in 
part, the absent portion being sometimes replaced by a fibrous 
cord. In other cases it may be remarkably small and so remain 
throughout life. The introitus may be occluded by an imper- 
forate hymen or by a similar membrane in any part of its course. 

The Uterus 

The uterus may be wanting, with or without the absence of 
one or more of the genital parts. It may be abnormally large 
or abnormally small ; and more frequently than is usually sup- 
posed it has abnormal flexions at birth. I have seen a few cases 
where the malposition was so marked as to be comparable to those 
disorders in the adult that are considered worthy of correction by 
some form of operative treatment. 

Most malformations of this organ represent some manner of 
persistence of the embryonal division into two cornua. Some- 
times these horns make up the whole uterus of the new-born 
child, sometimes they are connected only at the cervix so that 
there are two uteri ; in other cases the cervix and adjacent part 
of the uterine body are normal, but the upper portion of the body 
branches out into two horns ; a still other deformity is where only 
one of the original horns has developed naturally, so that the 
uterus is normal on one side, but on the other is flattened and 
without its tube. In some cases the uterus is of normal size and 
shape on the exterior, but the interior is divided by a complete 
or incomplete septum into two long canals. A very rare mal- 
formation is that of two wholly separate uteri; in such an event 
there might be separate cervices or a fused cervix and a single 
or double vagina. 

The Ovaries 

The ovaries may be absent when the uterus and tubes are 
likewise lacking ; or one may be wanting in children who are 



50 THE MEDICAL DISEASES OF CHILDHOOD 

otherwise normal. In other cases one or both may be abnormally 
small or only partially developed. Malpositions may occur even 
when the organs themselves are quite natural : thus they may be 
prolapsed into the inguinal canal or the labia majora; they have 
also been found in the foramen ovale or crural canal. 

The Fallopian Tubes 

Both tubes may be wanting when the uterus is lacking; or 
with an imperfect development of one side of the uterus the 
corresponding tube may be no more than partially elaborated. 
In other cases both tubes are only partially developed, especially 
if the uterus is more or less rudimentary. Either or both extrem- 
ities may be occluded, or the uterine junctions may be unnatu- 
rally situated. Sometimes the abdominal ends may be divided 
into two or more parts. 

The Mamma 

One or both mammae may be undeveloped or absent (amazia) ; 
or the nipples may be absent (athelia). These irregularities 
rarely occur alone, and almost always in connection with mal- 
formations of the thorax or genital organs. In other cases there 
may be supernumerary mammae (polymazia) or nipples (poly- 
thelia) or both ; the extra organs are often potentially active. 

The Penis 

The whole organ may be absent, or it may be rudimentary or 
the prepuce alone may be deficient. Where there is marked 
insufficiency of the penis, there are usually irregularities of other 
genital parts, especially the testicles. When it is wanting, the 
urethra is apt to open into the rectum. Partial malformations, 
such as hypospadias and epispadias, are not very rare. In the 
former there is an imperfect development of the penis, which com- 
monly is small, with a mucous-lined furrow on the inferior aspect. 
Near the root of the penis the urethra opens upon this furrow. 
The testicles may descend or remain in the abdomen, and the 
scrotum generally fails to unite in the middle, the two parts being 
attached in the manner of labia majora. In epispadias the urethra 
opens on the dorsum of the penis at one point or another between 
the root and the head. 

By some unexplained freak of development, the male and 



CONGENITAL MALFORMATIONS AND DEFORMITIES 51 

female elements may be parti}' combined in one cbild, forming the 
condition known as true hermaphroditism. In the so-called lat- 
eral form there is hypospadias, a testicle and spermatic cord on 
one side, and on the other a vagina, nterus, ovary, aDcl tribe. In 
the bilateral variety there is an ovary on one side and a testicle 
on the other. In pseudo-hermaphroditism there is a variation in 
the normal development of the foetal parts so that the resulting 
formation is atypical. There may be various grades in which the 
different parts may be almost entirely of one sex, or may be divided 
between the two. 

The Testicles 

One or both testicles may be absent without necessarily involv- 
ing the absence of epididymes, seminal vesicles, and spermatic 
cords. The connection between these various parts does not 
seem close enough to predicate from the presence or absence of 
one the presence or absence of any other one or all of them. In 
some cases the testicles may be undeveloped, but the epididymes 
may be in a normal state in the scrotum, and in others the sper- 
matic cord may also be present. 

A not infrequent abnormality consists of the retention of one 
or both testicles in the abdomen, called cryptorchidism. Normally 
these organs should descend into the scrotum about the seventh or 
eighth month of intra-uterine life ; in some few cases they may 
descend at some later period up to adult age. Usually, however, 
they remain in the abdomen unless freed by operative interfer- 
ence. The causes are many, and include unusual size or partial 
development of the testicle, deficient gubernaculum testis, insuffi- 
ciency of the vaginal process of the peritonaeum, narrowness of 
the inguinal canal, adhesions from fcetal peritonitis, and various 
malpositions of the testicle. As a rule, one side only is involved, 
and the retained organ may be found in the inguinal canal, in the 
crural canal, or in the perinaBum. It may remain normal or may 
undergo some form of degeneration. 

Congenital Dislocations 

Congenital dislocations are not often seen ; of those which are 
recognized about ninety per cent affect the hip. These are 
oftener seen in girls than in boys, and are located on the two 
sides in about an equal degree. 



52 THE MEDICAL DISEASES OF CHILDHOOD 

In the vertebral column dislocations may occur between any 
two bones ; also the cranium may be luxated forward or backward. 

The inferior maxilla may be dislocated forward on one or both 
sides. 

The clavicle may be dislocated at either or both extremities. 

The shoulder joint may be dislocated on either or both sides. 
The deformity may be subglenoid, subcoracoid, and subacromial, 
or subspinous. Speaking in round numbers, one may say that 
about fifty per cent of the cases are bilateral. 

The elbow has been known to be dislocated in various ways : 
the whole forearm has been luxated backward, the head of the 
radius has been found above and behind its usual position, the 
head of the radius has slipped forward, and the head of the radius 
has been pushed upward and outward. 

The dislocations at the wrist constitute " club-hand," and com- 
monly occur in connection with club-foot. The hand may be 
turned inward, outward, backward, or forward. A similarly 
large range of deformities has been noticed in the fingers. 

At the knee the dislocation may be either forward or back- 
ward. The former is by far the more frequently seen. Luxation 
at the ankle has likewise been reported. 

All of these deformities are susceptible of a variable degree of 
correction, if the child has a fair amount of vitality, by means of 
orthopaedic appliances or operation. Subluxations, likewise, are 
amenable to treatment, and the prognosis is better than in full 
dislocation. 

There may be supernumerary fingers or toes of various degrees 
of organic development; or one or more fingers or toes may be 
congenitally absent. Webbed fingers and toes are a not un- 
common deformity. For full details the reader should consult 
special works. 



CHAPTER V 
INJURIES AND DISEASES OF THE NEW-BORN 

Caput Sttccedaneum 

Most new-born children have a tumor on the part of the head 
which has been least pressed upon and squeezed that is known as 
caput succedaneum. The constant pressure on the part of the 
scalp which is held, as if in a vise, by the bony pelvis necessarily 
makes a corresponding congestion in the free portion on the oppo- 
site side of the head. The tissues of the scalp and fascia become 
infiltrated, distended, and finally form a heavy, baggy tumor whose 
size is in proportion to the duration and intensity of the pressure 
exerted upon the head. The infiltration is commonly situated 
over the parietal bone on the side which first presents ; or there 
may be certain natural variations : instead of being unilateral the 
swelling may cover two sides, as the result of long pressure after 
the head has come down to the external genitals ; or there may be 
a primary and secondary tumor, the first of which occurs as de- 
scribed above, while the second originates in a similar fashion, 
after anterior rotation has occurred, and is situated in the mesial 
line. The same process may happen to the shoulder in shoulder- 
presentation, and in the same way the free side, which naturally 
presents first, bears the tumor. 

No treatment is necessary, for in a few days the infiltration 
will disappear by absorption. Manipulation, bandaging, massage, 
and inunctions are mischievous, since they are apt to break the 
skin and change an aseptic to a septic condition. If such a mis- 
fortune occurs, the ordinary surgical measures hold good. 

Cephalhematoma 

Children who are weak, amernic and badly nourished, who are 
born of debilitated and exhausted mothers, sometimes show at 
birth a blood-tumor of the head that is called cephalhematoma. 

53 



54 THE MEDICAL DISEASES OF CHILDHOOD 

Two sorts are seen : one lies beneath the periosteum and is called 
a true cephalhematoma ; the other lies under the aponeurosis of 
the scalp and is called false cephalhematoma. The mysterious 
alterations in the blood or vessels which make hemorrhage from 
debilitated subjects easier than from those in robust health seems 
to be the active cause in this disorder. When the blood has 
escaped, it collects between the cranium and pericranium, and so 
prevents the deposition of new cells from the bone-producing 
layers of the periosteum ; but at the margin, where the cranium 
and periosteum meet, a hard circle shows where bone-production 
has gone on without interruption. Occasionally such a tumor 
may form after birth from injury or clumsy manipulation. 

The distinction between cephalhematoma and caput succeda- 
neuin is not usually hard to make. In the former the tumor is 
not on the presenting part as it is in the latter ; in the former the 
swelling is sharply marked off from the rest of the scalp, while in 
the latter it gradually merges into the surrounding surface ; the 
first has fluctuation at the centre, but the second has not; the 
first does not necessarily attend a severe or prolonged labor, while 
the second does ; the one presents no discoloration of the skin, 
but the other is usually covered by scalp of a dark red or bluish- 
red hue ; the first tends to increase after birth, while the second in 
the same space of time diminishes ; the first never occurs over 
sutures or fontanelles, but the second does. In addition, palpa- 
tion in cephalhematoma furnishes a sensation, caused by pressure 
upon the particles of newly formed bone, as if one were crackling 
paper. 

The treatment of cephalematoma is conservative. Most 
cases improve under a protective dressing and the application of 
measures which will develop the child's vitality. If infection 
occurs, the tumor must be freely opened, drained, and packed. 

HEMATOMA OF THE STERNO-CLEIDO-MASTOID MUSCLE 

In some weak or prematurely born infants a fibrosis of one 
or both sterno-cleido-mastoid muscles occurs as the result of a 
difficult or violent delivery. There may be a tearing of the 
muscle-fibres with a greater or less amount of hemorrhage. The 
head is for a considerable period inclined toward the uninjured 
side, although the deformity is not necessarily permanent. If, 
however, healing takes place with the formation of adhesions and 



INJURIES AND DISEASES OF THE NEW-BORN 55 

strong fibrous bands, a torticollis may result, and is with diffi- 
culty corrected. These cases usually occur in foot and breech 
presentations. Such an instance of wry -neck is to be differen- 
tiated from a congenital torticollis whose origin is unassignable. 
No medicinal treatment is required ; some advantage in the way 
of preventing the formation of adhesions may be gained by gentle 
massage or passive motion ; a somewhat harsher method of obtain- 
ing this result is by the use of a well-padded apparatus that is 
designed to keep the infant's head and neck in a correct position. 
If, however, firm adhesions have been allowed to form, the usual 
operative measures are indicated. 

Visceral Hemorrhage in the New-Born 

Haemorrhages may occur at birth or within the next few days 
in one or more parts of the body. Commonly the condition is 
impossible to diagnosticate, and is fully recognized only on 
autopsy. The cause has never been fully understood : in some 
cases a violent, spontaneous, or artificial delivery seems to be 
responsible, but in others, where the pelvis was large and the 
foetus small, this supposition could not be entertained. Some 
unknown alteration in the character of the blood or the vessels 
has been suspected ; and we know that children born of mothers 
who had suffered from sy^philis, tuberculosis, or acute infectious 
diseases during or at the end of pregnancy sometimes become 
subject to haemorrhages for little or no ostensible provocation. 
Some observers have claimed that infection by pathogenic micro- 
organisms, such as streptococci, may cause the bleeding. On 
the whole, one may say that the aetiology is no more than con- 
jectural. 

The loss of blood may be minute or great enough to cause 
death. The most frequent location is in the brain and menin- 
ges ; the lesions are not attended by inflammatory processes. In 
the liver, the suprarenal capsules, the kidney, the lungs, the 
intestines, and peritonaeum the haemorrhages occur in varying 
frequency, but rarely, if ever, give symptoms by which one can 
recognize them. In the lung there may in some cases be the 
signs of consolidation, with subnormal temperature, blue and 
cyanotic skin, and marked lack of vitality. 

There is no treatment for these conditions. 



56 THE MEDICAL DISEASES OF CHILDHOOD 

" HEMORRHAGIC DISEASE " OF THE NeW-BoKN" 

This provisional name has been given to a class of cases which 
are characterized by haemorrhages, usually small in amount, from 
the surface or viscera of the recently born child. The aetiology 
has for a long time been a matter of dispute, but probably inheres 
in a small bacillus, described by Gaertner, which resembles bacte- 
rium coli commune. The haemorrhages occur within the first few 
days or certainly within the first month of life. No constant le- 
sions, excepting the haemorrhages, have been found. The whole 
matter has so little of absolute clearness about it, that one cannot 
be certain whether most haemorrhages, which occur at or before 
birth, should not be included in this category. 

The loss of blood may occur from the umbilicus, intestines, 
stomach, mouth, lungs, pleura, kidneys, ureters, the mucous mem- 
branes, the meninges, and the skin. Usually these haemorrhages 
are multiple. There may be associated symptoms of loss of flesh 
and strength, high or subnormal temperature, and, in some cases, 
convulsions. The course of the disease seems to be self-limited 
and not affected by treatment. In most cases the children die 
after a few days. 

The care of the disorder is symptomatic. 

Obstetric Paralyses 

Pressure lesions of the nervous system may occur during par- 
turition to all classes of cases ; but those of weak vitality or im- 
poverished heredity more easily fall victims to such disorders than 
children who are more fortunately constituted. In almost all 
cases the active cause is some form of haemorrhage that inflicts 
pressure and consequent degeneration upon some part of the cere- 
bral, spinal, or peripheral systems. Such haemorrhage is not often 
spontaneous but rather the result of violence, due in most cases 
to long and difficult labor. The use of forceps is calculated to 
decrease rather than increase this danger, especially if they are 
rightly manipulated. Also, it is possible that some form of vio- 
lence may affect the child, such as a fall or blow upon the 
mother's abdomen before parturition, or allowing the child to fall 
while handling him. In this way congestion and concussion of 
the brain may arise, or even a fracture of the skull. In rare 



INJURIES AXD DISEASES OF THE XETT-BORN 57 

cases, a condition of sepsis may favor the tendency toward cere- 
bral bleeding. 

Most of these haemorrhages are cerebral, and of these, the ones 
at the base are oftener seen than those of the convexity. In snch 
cases, similar lesions are found in other parts of the body as well ; 
one of the commonest of these is the upper spinal cord and its 
membranes, and then next in frequency come the viscera. The 
peripheral paralyses are generally caused by the pressure of forceps 
upon some bony part where a nerve may be injured. This results 
in partial or total disability of the face or arm. The facial nerve 
and brachial plexus are thus not in the same class as the cere- 
brum, and their disabilities as a rule do not last so long. The 
spinal paralyses occur almost entirely in connection with injuries 
of the head, for it is rare to find a direct trauma of the cord or 
vertebras alone. The symptoms differ widely in various cases, 
corresponding closely to the amount of pressure produced, as well 
as its locality. Each case is therefore a study in focal relations. 
A small haemorrhage may give rise to nothing more than some 
degree of dulness with or without rigidity and convulsions. With 
cortical haemorrhages there may be monoplegia, hemiplegia, di- 
plegia, or paraplegia. In such cases there may be the accompany- 
ing symptoms of slow respiration and pulse, nystagmus, contraction 
of the pupils, and even opisthotonos. If the amount of blood is 
very large, it may cause a bulging of some part of the skull or 
distention at the sutures. 

Facial paral} T sis, when peripheral, is not often a permanent or 
serious disorder. In this case the whole side may be affected, it 
looks smooth or swollen, lacking the usual markings and folds ; 
simultaneously, the mouth is pulled toward the other side. A 
diagnostic sign, which distinguishes the facial paralysis of central 
origin, is the fact that in such case only the lower half is affected. 
In very marked cases the electrical reaction of degeneration may 
be present. 

In peripheral paralysis of the arm we have such injuries as can 
be produced by the margin of the forceps pressing upon the neck, 
by the impact of a finger which was placed in the axilla for the 
purpose of traction, or even by a tightly strained cord about the 
neck. The parts usually affected are those muscles supplied by 
the fifth and sixth cervical nerves ; among them are the biceps, 
deltoid, supinator longus, brachialis anticus, supraspinatus, and 



58 THE MEDICAL DISEASES OF CHILDHOOD 

infraspinatus. A paralysis of some or all of these muscles con- 
stitute the so-called Erb's type. In a characteristic case the arm 
is helpless, is rotated toward the body so that the palm of the 
hand is directed away from the body. The severity of the injury 
decides not only the amount of paralysis but also that of anaesthe- 
sia, atrophy, and electrical reaction of degeneration. Usually, the 
disability is transitory, and at the end of a few days or weeks 
motion is satisfactorily restored. Nevertheless, cases of perma- 
nent effects, such as atrophy, subluxation, and dislocation, occa- 
sionally occur. 

The treatment in all these disorders is slight. Passive motion 
and massage of the affected muscles, may, with the help of nor- 
mal growth and development, hasten a return to natural useful- 
ness. Doubtless some good may be obtained from orthopaedic 
apparatus for the prevention of subluxation and ultimate disloca- 
tion ; at the same time, however, too much reliance should not be 
placed upon such purely mechanical means. The advantages to 
be derived from the use of electricity are doubtful. 

Asphyxia 

Before birth the foetus is remarkably well supplied with oxy- 
gen ; when birth takes place the attendant phenomena include 
cessation of this supply. The resulting oxygen-hunger, or relative 
over-supply of carbonic dioxide, as some authorities prefer to say, 
causes a stimulation of the respiratory centres, and the child be- 
gins to breathe. The anterior edges are first inflated, followed by 
the superficial parts of the upper lobes, the deeper parts, and thus 
gradually the air works its way down to the lower lobes, first on 
the surface and then to the interior. The process is not always 
perfectly regular nor very rapid, so that complete aeration may 
not ensue for days. 

While most children experience little or no trouble in the tran- 
sition from prenatal to postnatal breathing, a fairly large propor- 
tion suffer some degree of asphyxia. The causes may be personal 
or maternal, intra-uterine or extra-uterine. The child may be so 
deficient in muscular and nervous force that he is unable, from 
sheer inanition, to begin or carry out the necessary movements. 
Or, as the result of a huge liver, syphilitic inflammation of the 
lungs, tumors, or anasarca, he may be similarly impotent. Under 
the intra-uterine causes we include the conditions of pressure upon 



INJURIES AXD DISEASES OF THE XEW-BORX 



59 



the umbilical cord, the placenta, or foetal brain, premature freeing 
of the placenta, and tight wrapping of the cord about the neck ; 
in other cases there may be a long second stage of labor, uraemia, 
or death of the mother. The extra-uterine causes are injuries 
inflicted during or directly after labor, and malformations of the 
respiratory, circulatory, and cerebral systems. 

As the result of these circumstances the lungs may be not at 
all aerated or only in small part, the brain and thoracic viscera 
may be congested and studded with haemorrhages, and in the air 
passages there may be small amounts of foreign matters that have 
been aspirated. The blood is dark and thin, the right heart is 
dilated, the serous cavities may contain serum. 

If the asphyxia is slight in degree, the child looks cyanotic and 
puffy, the attempts at respiration are few and weak, the pulse is 
slow and fairly strong. The condition may change for the better 
or may pass into a more serious degree where the heart-action is 
very weak or inaudible, the face is pale, muscular contractility 
has ceased, and appreciation of external stimuli is lost. 

Treatment. — A routine procedure is to clear the mouth by 
means of a piece of fine lint soaked in boracic acid of mucus 
and material that may be taken in from the vagina or uterus. 
The child may then be held in the inverted position, and if addi- 
tional stimulus is needed, it may be supplied by sprinkling with 
cold water, spanking with the hand or a wet towel, or alternate 
immersion in hot and cold water. If the degree of asphyxiation 
is too great to be thus relieved, one or more of the various meth- 
ods of artificial respiration should be used. There are so many 
of these that one has a large choice ; and in making a decision, 
the very important factor of preserving the body heat should be 
kept in mind. For this reason the child should, if possible, be 
kept in a hot bath Avhile the efforts for resuscitation are making. 
With proper support Sylvester's method can thus be used. This 
is practised by placing the child on his back with the shoulders 
slightly raised. The arms are then to be grasped above the 
elbows and rhythmically extended above the head and depressed 
against the sides of the thorax at a rate which approximately imi- 
tates 'the frequency of respiration at birth. Forest's practice is 
also commendable : he first places the child on his left hand, face 
down, and then clears the obstructions from the mouth and throat 
by pressure with his right hand on the back. Next the infant is 



60 THE MEDICAL DISEASES OF CHILDHOOD 

placed in a hot bath in a sitting posture, the back being supported 
by the physician's left hand. With his other he grasps the little 
hands and raises them on high, at the same time blowing in the 
child's mouth. Then he brings the arms down, bends the body 
forward, and compresses the chest. Schultze's method is good 
but somewhat violent. In practising it, one holds the child to 
the front, one's thumbs on the breast, index fingers in the axillae, 
the other fingers spread around the back, while the infant's head 
rests upon the upper part of the palms. The infant is then gen- 
tly swung upward until his head points nearly down and his 
feet and legs are forward on the abdomen, his chest being held 
firmly fixed by the operator's thumbs and fingers. In this posi- 
tion the physician's arms are almost straight in front of him. The 
child is then swung back to the first position, when the whole pro- 
cess is repeated. While this method has many advantages, it has 
dangers for a weak heart, and may, moreover, if done roughly, 
result in producing a fracture of a bone. Various other methods 
such as Dew's, Duke's, Richardson's, Ribemont's laryngeal infla- 
tion and Laborde's lingual traction, may be used. The main re- 
quirements are freeing the mouth and throat of mucus, continued 
heat, a satisfactory method of artificial respiration, and the pres- 
ervation of one's presence of mind, judgment, and tireless patience= 

Congenital Atelectasis 

This condition represents a collapsed and unaerated state of 
any part of the lung. It may be primary, as when a part or all 
of a lung has not been dilated by air ; or it may be secondary, as 
in those cases where aeration has taken place, but is followed by 
collapse of the lung tissue in question. Its causes are those of 
asphyxia, with which it is inseparably connected ; for atelectasis 
is in fact a localized condition of asphyxia. 

The parts of the lung most frequently involved are the same 
as in asphyxia ; namely, the interior, inferior, and posterior por- 
tions. The extent may be very small or great, and sometimes 
there are several minute areas. They are of a dark red color, 
heavy, hepatoid, non -crepitant, showing lobulations. Even after 
being in the collapsed condition for days or weeks, they can, with- 
out much effort, be artificially aerated. Where inflation has taken 
place in parts, there is almost always some degree of compensatory 



INJURIES AND DISEASES OF THE NEW-BORN 61 

emphysema near the atelectatic areas. In the pleura small 
haemorrhages may sometimes be seen ; the right heart is dilated, 
the liver, spleen, and gastro-intestinal mucous membranes are 
congested and possibly swollen to a noticeable degree. In some 
cases there is a cerebral hyperemia and even minute punctate 
haemorrhages. Deformities of the heart are found in some rare 
instances. 

Symptoms. — In the primary form the children die at or shortly 
after birth. Respiration may practically not begin at all, or it 
may be weak, shallow, incompetent, and plainly is not produced 
by the whole lung. There will be cyanosis, weak pulse, pos- 
sibly convulsions, and finally death. In the secondary or post- 
natal form the lungs have seemingly become aerated, and then 
have fallen into a condition of partial collapse. Nevertheless 
there is a disposition toward cyanosis, of which there may be a 
number of attacks. The child is weak, the circulation impeded, 
the temperature at times subnormal. Either the attack may be 
sudden and rapidly fatal, or there may be one or more periods of 
improvements. Each exacerbation leaves the patient more ex- 
hausted than he formerly was. Intercurrent diseases are feebly 
withstood and sometimes are the occasion for a new and often 
fatal attack of atelectasis. When the end comes, it is sometimes 
preceded by convulsions. The collapsed area may give a dimin- 
ished percussion note, the breathing is slightly harsh or even bron- 
chial and immediately beyond the borders there may be poorly 
defined signs of emphysema. 

Treatment. — Prophylaxis is a large paft of the treatment. The 
physician should see to it that every child cries enough in the first 
week or two to insure proper pulmonary aeration. If the attack 
takes place, heat should be applied to the body and artificial res- 
piration must be practised. The treatment of atelectasis is that 
of asphyxia. 

Icterus Neonatorum 

Infants at any time within the first few days may become jaun- 
diced, the favorite times being the third, fourth, and fifth days. 
When the jaundice is not due to distinct disease, such as congeni- 
tal malformations of the bile-ducts, syphilis of the liver, or septic 
infection, it is called physiological icterus. The cause of it is un- 
known; some investigators believe that it is an evidence of resorp- 



62 THE MEDICAL DISEASES OF CHILDHOOD 

tion caused by stasis in the bile-ducts, others that it is caused by 
the swelling of Glisson's capsule and oedema of the hepatic vessels, 
others that it results from the breaking down of red blood cor- 
puscles soon after birth, still others that it is due to the great num- 
ber of red blood-cells formed in the liver. No one theory has been 
found to apply to all cases, and the single factor that the majority 
of investigators agree upon is that it is hepatogenic in origin. 

The symptoms consist in the pigmentation which may color 
every part of the body. Usually it begins on the chest or face 
or eyes, and then it may spread more and more. The skin and 
mucous membranes may be stained in various degrees, and prac- 
tically every internal portion of the body has been found to be 
similarly colored. The fseces are generally unchanged; the urine 
may be normal, or more or less tinged, occasionally containing bile 
pigment and an excess of urea and uric acid. No other manifes- 
tations are noticeable. It may be of some interest to note that 
weak children seem to take on a deeper stain than robust ones. 
The condition may last from a few days to two or two and a half 
weeks. No treatment beyond the ordinary care is necessary. 

Acute Pyogenic Infection 

Acute infections of pathogenic micro-organisms are one of the 
dangers of very early life which are particularly dangerous on 
account of the infant's feeble faculty of resistance. The micro- 
organisms which are most commonly found are the streptococcus, 
staphylococcus pyogenes aureus, and those encountered in the 
parturient canal of the mother. The infection takes place through 
the umbilicus, the mouth, the air passages, and possibly through 
the alimentary tract. Wounds, cracks, and abrasions of the skin 
can certainly act as the place of admittance. The matter is one of 
plain pathological contamination such as we are most familiar with 
in surgical diseases. The umbilical vessels and the umbilicus 
with the surrounding connective tissue are the commonest regions 
affected. The arteries are more commonly involved than the vein, 
and in both structures the infection may be of various degrees of 
severity and may extend for various distances along their course. 
Infection of the umbilicus may occur alone, but more often it is 
consequent or subsequent to infectious arteritis and phlebitis. In 
the large majority of cases such a condition marks the beginning 
of a process which finally involves any part of the body in throm- 



INJURIES AND DISEASES OF THE NEW-BORN 63 

bus-formation and the scattering of pyogenic micro-organisms and 
their toxines. Thus a localized or general peritonitis frequently 
follows an omphalitic infection; in some cases an inflammation of 
the gastro-intestinal track occurs which in all likelihood is com- 
municated from the peritonaeum rather than the food. The liver 
may be invaded, as an extension of the primary infection, in the 
form of a purulent inflammation of the portal vein or its branches, 
or an interstitial hepatitis. In the lungs there may be a purulent 
bronchitis or disseminated broncho-pneumonia with variable in- 
volvements of the pleura. From the same source and as a rule 
following the pleuritis there may be an inflammation of the peri- 
cardial sac that should be regarded as a severe and terminal mani- 
festation. Another rare localization is a pseudo-membranous 
inflammation of the throat that is streptococcic in origin, bearing 
no relation to true diphtheria. Other forms that occasionally are 
seen are meningitis, erysipelas, multiple abscesses in the cellular 
and muscular tissue, arthritis and osteomyelitis. There is nothing 
peculiar about them excepting the difficulty of obtaining well- 
defined objective symptoms. 

These symptoms are characteristic of nothing in particular ex- 
cepting general septic infection. There may be progressive loss 
of flesh and strength, variable temperature, disorders of the gastro- 
intestinal track, haemorrhage, icterus, nervous and cerebral symp- 
toms. Some of the local signs are hard to distinguish, such as 
those of the broncho-pneumonia, pericarditis, internal haemor- 
rhages. The external manifestations, such as abscesses, arthritides, 
erysipelas and superficial omphalitis, are naturally noticed without 
delay or trouble; but there is always danger of one of them being 
regarded as the whole cause of the sickness rather than as a par- 
tial and local manifestation of an infection that in all likelihood is 
sweepingly general. 

The treatment of this condition is largely symptomatic ; in ad- 
dition, the best that one can do is to stimulate the child's physical 
resources to the utmost and to fight the sepsis by such surgical 
means as are practicable. The prognosis is always a gloomy one. 

Ophthalmia Neonatorum 

An important percentage of all births, especially in institutions 
and among ignorant people, show a purulent ophthalmia. The 
severe and some of the mild cases are due to an infection of the 



64 THE MEDICAL DISEASES OF CHILDHOOD 

conjunctiva with the gonococcus. The source of the infection is 
the mother's genital track, the child's toilet utensils, the hands, 
instruments, and dressings of the attendants. The milder cases 
may be due to irritating discharges of the maternal vagina, other 
micro-organisms than the gonococcus, and uncleanliness. 

Usually the discharge begins within the first week; at first it 
is slight and with it go swelling and congestion of the lids. 
There is an infiltration of the bulbar conjunctiva which partially 
hides the cornea. The whole conjunctiva is bright red, smooth, 
covered with small whitish patches. The discharge becomes 
thicker, more profuse, and may be mixed with small amounts of 
blood and serum. As the disease approaches the end of its course 
unchecked, the conjunctival mucous membrane becomes dark, re- 
laxed, rough, and necrotic. Under such circumstances the return 
to health is slow and imperfect. On account of the great chemo- 
sis, the integrity of the cornea may be most seriously impaired. 
As a consequence, total haziness or one or more ulcers may form 
and fmall} T cause perforation. There may then follow pyramidal 
cataract, adherent leucoma, or staphyloma. The destruction may 
vary all the way from slight scars to a panophthalmitis whose nat- 
ural outcome is atrophy of the bulb. 

Treatment. — Prophylaxis should always be carefully practised 
both in institutions and in private cases where the environment is 
not favorable to health and cleanliness. An efficient method con- 
sists in washing out the child's eyes as soon as possible with a boric 
acid solution followed by the installation of a few drops of a one- 
half per cent solution of argentic nitrate. Even in cases of doubt 
this should be done, since nothing can be lost and everything 
gained thereby. If the disease has once begun, the eyes must be 
thoroughly douched out about every thirty minutes, according to 
the severity of the inflammation and the amount of discharge, with 
a copious supply of boric acid solution held in a fountain syringe at 
no great distance above the patient's head. In the meanwhile the 
affected eye must be kept covered with iced cloths which are to 
be changed every two or three minutes, day and night. Some 
authorities advise the use of the silver solution daily; others cau- 
tion against its use after the swelling and infiltration are intense, 
since the cupping about the cornea tends to hold some of the irri- 
tating fluid in the depression and so gives rise to epithelial de- 
struction. Both methods have successes and failures in their 



INJURIES AND DISEASES OF THE NEW-BORN 



65 



results; and doubtless one can get good results from the boric 
acid douching if it is thoroughly and frequently done. If, on the 
other hand, it is not conscientiously carried out, the aid that sil- 
ver gives is at best doubtful. If only one eye is involved, the 
other should be protected by means of a watch glass whose mar- 
gins are kept securely and effectively protected and in place by 
strips of plaster. 

The disease is always a serious one, even when the care is 
good ; but when it is intermittent or imperfect, the result is some 
degree of destruction of the eye. In this disease constant watch- 
fulness and work are the price of sight. The non-gonorrhceal 
cases are naturally apt to be less severe. 



Infectious H^emoglobin^mia 

In 1873 Charrin, of France, described a disease, and reported 
fourteen cases of it, which was later investigated by Winckel. In 
1879 the latter reported twenty-three cases of it that occurred in 
a Dresden institution. After this report the disease was known 
as Winckel's disease or epidemic hemoglobinuria. Its nature 
and course seem to be acutely infectious, but what the exact cause 
is remains unknown. It usually attacks infants in the first week 
of life and has a short duration of one, two, or three days. 

The lesions do not cast much light upon the disease. In most 
of the viscera, minute haemorrhages have been found ; there is 
swelling of the liver, spleen, Peyer's patches, and the mesenteric 
glands. In the heart and liver there are areas of fatty degenera- 
tion which doubtless may extend to other parts. The blood con- 
tains a high percentage of hemoglobin which has also been found 
free in the serum. There is free blood-pigment in the spleen 
and its blood-vessels. In the kidneys, the cortex is broad, there 
are streaks and spots of darkened pigmentation in the pyramids, 
and the straight tubes are filled with haemoglobin. 

The symptoms are abrupt and short-lived. The child becomes 
weak, fretful, rapidly exhausted and may fall into convulsions be- 
fore death. The temperature fluctuates about the normal mark, 
but is not characteristic. In the first few hours the child's com- 
plexion becomes cyanotic and then jaundiced ; both colors increase, 
so that the hue is finally a shade of brown. The pulse and breath- 
ing are rapid, the stomach and intestines may show functional dis- 



66 THE MEDICAL DISEASES OF CHILDHOOD 

orders. The urine is, on account of the presence of hemoglobin, 
brown in color, and contains epithelial debris, blood cells, granu- 
lar casts, bacteria, and some albumin. 
The treatment is symptomatic. 

Fatty Degeneration of the New-Born 

This disease, described by and called after Buhl, is a rare con- 
dition about which very little is known. It may attack any child, 
but has been noticed to a greater extent in those who were par- 
tially asphyxiated than where birth was quite normal. Its cause 
is unknown, and it occurs in isolated cases. 

Throughout the body there are hemorrhages of various sizes ; 
they may v be found in the skin, in the brain, the viscera, the 
mucous membranes, and serous cavities. Throughout the viscera 
there may be a disseminated parenchymatous inflammation that 
is finally replaced by a fatty degeneration. This process is not 
equally diffused in all cases, nor does it proceed in an even degree 
in all parts. The cord is commonly normal. 

The preliminary history is often one of asphyxia, for which no 
good cause may be found. After a few days the child's com- 
plexion is seen to change ; it may become somewhat icteric and 
cyanotic, although these two elements are not necessarily com- 
bined in equal degree. In some cases the skin may be oedematous, 
and in a large percentage of cases it is stained with hemorrhages. 
When the cord falls off it may be seen to be normal, although the 
tissue round about may be the seat of parenchymatous hemor- 
rhage ; the same process may be present in any of the external 
parts, especially the mucous membranes. There may be func- 
tional disorders of the stomach and intestines, the heart is weak 
and irregular, and the whole economy falls into progressive 
prostration. 

The treatment is merely symptomatic and in severe cases is 
of no avail. Death usually comes before the disease has run for 
two weeks. 

Pemphigus in Infants 

This term designates a symptom that occurs in more than one 
disorder. It may be a manifestation of a contagious skin disease 
which may be communicated from the mother or attendant to the 
child or vice versa. Again, it may occur as one of the symptoms 



INJURIES AND DISEASES OF THE NEW-BORN 67 

of hereditary syphilis, or it may result from exposure to a very 
hot bath. 

The disease is characterized by the appearance on the skin of 
a few or many bullae or blebs which are filled with clear serum. 
In syphilis they commonly break out on the palms and soles dur- 
ing the first few days of life, but may extend to other parts. 
These children are commonly very weak and puny, and in this 
respect they show a marked difference from the robust infants 
who contract the infectious disease. In the latter the trunk, espe- 
cially the buttocks and adjacent areas, and the extremities rather 
than the palms and soles are involved. Where the eruption is very 
plentiful it may even attack the mucous surfaces. The blebs are 
small or large, they may be single or coalesced, and they rest on 
a pinkish base. After a few days the blebs may rupture and 
dry up, leaving a pink or reddened scar that after a time dis- 
appears. The duration of the eruption has no fixed limit, nor 
is the number of crops certain. 

The treatment consists in general care and the application of 
boracic acid dusting powders. The syphilitic children have a 
much poorer chance of recovery than the more vigorous subjects 
of the infectious disease. 

Umbilical Polypus 

The umbilicus may instead of healing promptly assume a 
polypoid or granulomatous development. The new tissue is 
tender and friable, and discharges a small quantity of thin fluid. 
It may be removed by the application of silver nitrate stick. 
These applications are best made in decreasing circles from day 
to day, rather than in an attempt to remove the whole structure 
at one time. After each application the area should be protected 
by a dressing of a simple cerate, gauze and a roller bandage. 

Diverticulum Tumor of the Umbilicus 

This condition is also called adenoma of the umbilicus and 
congenital mucous polypus of the umbilicus. It occurs in con- 
nection with Meckel's diverticulum, a cylindrical process giving 
off from the ileum about a metre above the ileo-cascal valve ; 
it is rudimentary, being a retention of a part of the omphalo- 
mesenteric duct. In some cases it is no more than a small 
blind sac connected with the ileum, in others is an open 



68 THE MEDICAL DISEASES OF CHILDHOOD 

passage leading from the intestine to the umbilicus, and 
thereby producing a fistula. If for any reason the mucous 
membrane prolapses, a mucous tumor, pierced in the centre, ap- 
pears at the umbilicus. As more and more of the tube is forced 
out, the tumor becomes steadily larger, until it may contain one or 
more folds of gut. As the knuckle of the intestinal wall is forced 
through the opening there will naturally be two apertures, one 
leading to the lower, and the other to the upper, part of the 
bowel. The tumor is irreducible and, as stated above, contains 
two fistulas. Between this extreme form and the slight forms 
consisting of a bit of mucous membrane in a polypoid form there 
are many gradations. The closing of the slight form is not a 
difficult matter ; the operation on the advanced form is an im- 
portant one and may be beset with unexpected obstructions and 
malformations. 

Umbilical Hernia 

A small hernia at the umbilicus is a matter of frequent occur- 
rence, in girls oftener than boys, and in poorly nourished girls 
most of all. The usual cause is straining, due to violent crying, 
pain and constipation. It is not often larger than one's finger nail 
and rarely occasions trouble ; but when the trouble does occur it 
takes the serious form of strangulation. The treatment in most 
cases is merely preventive : after the cord has fallen off, a pad 
should be held in place over the umbilicus for two, three, or four 
months. After that time it is unnecessary. If the hernia de- 
velops to a noticeable size, it may be held in place by a wooden 
button which is securely strapped down by strips of adhesive 
plaster. Another truss that has given me good service is a small 
truncated cone of beeswax with its blunt apex fixed in the hernia 
and held in place by adhesive plaster. If such means are insuffi- 
cient, a radical operation then comes under consideration. In 
most cases, however, little or no treatment is required ; but in 
the presence of any form of pressure the surface must be well 
covered with a bland dusting powder to avoid the likelihood of 
irritations of the skin. 

Mastitis 

An inflammation of the breast in very young infants may be 
either idiopathic or the result of septic infection. The first sort 
is frequently seen in every large clinic for children. Within the 



INJURIES AND DISEASES OF THE NEW-BORN 



69 



first two or three weeks of life the breasts of both male and fe- 
male infants may secrete a fluid that looks like colostrum and has 
the chemical composition of ordinary human milk. Such a devel- 
opment has no practical importance and gives merely temporary 
inconvenience. The breasts are swollen, tender, and on pressure 
give out a few drops of lacteal secretion. If, however, they are 
subjected to rough handling, squeezing, massage, or injury of any 
sort, the delicate skin may be broken and pyogenic germs may 
enter. The result is an abscess with the ordinary symptoms of 
pus-formation : fever, malaise, local pain, swelling, and redness. 
This pus-process may occur in various degrees of severity, and its 
consequences naturally become of equal moment. 

The so-called physiological mastitis requires no especial treat- 
ment. The surface must be kept scrupulously clean, the breast may 
be covered with absorbent cotton which is to be held in place by 
a soft flannel roller bandage. Care must be exercised to avoid 
any sort of injury to the affected part. If the mastitis becomes 
infected and purulent, it must, like any other abscess, be treated 
by free incision and draining. 

Intestinal Obstruction in the New-Born 



Abnormal conditions of the intestines at or shortly after birth 
may cause partial or complete obstruction. Partial obstruction 
may be due to neoplasms, to bands and fibres, such as a persistent 
omphalo-mesenteric duct. In other cases it may be due to a ste- 
nosis or partial atresia of the intestine at any point from the pylo- 
rus to the anus. Complete obstruction is commonly due to 
malformations in which some part of the intestinal tract is absent 
or so undeveloped that it resembles the lash of a whip. Such 
deformities are oftenest seen in the lower third of the rectum, but 
they may also occur on any plane. 

The symptoms of partial obstruction are great and increasing 
difficulty in having normal passages, plus a growing tendency to 
vomit ; after a short time one may be able to distinguish a tumor 
about and above the obstruction, followed by the formation of 
gases in the abdomen. The child grows weaker and weaker until 
his condition soon becomes alarming. If the obstruction is 
total, there will be no movements except the passage of meconium 
and mucus ; the abdomen soon becomes filled with gases, vomiting 



70 THE MEDICAL DISEASES OF CHILDHOOD 

sets in without delay, especially if the obstruction is high in the 
gut, and the child within a short time collapses. Vomiting is not 
longer delayed than one or two days, and death results within the 
week. 

Obstructions in the rectum and imperforate anus may often be 
relieved by immediate operation. When the obstruction is situ- 
ated above the rectum, an artificial anus may temporarily relieve 
the child; but malnutrition and severe intestinal disorders are 
apt to set in and give a fatal result. 

Hernia of the Diaphragm 

A congenital absence of the diaphragm to a greater or less 
extent may occur, usually on the left anterior border. Through 
the opening a knuckle of gut may force its way, and then draws 
after it more and more of the intestinal tube. There will be cor- 
responding symptoms of displacement of the heart to the right, 
imperfect expansion of the lung, tympanic percussion note and, if 
the intestine in large amount has found its way into the thoracic 
cavity in intra-uterine life, the lung may be undeveloped. The 
younger the child, and the larger the loop of escaped intestine, the 
sooner is death apt to occur. 

Sclerema Neonatorum 

This condition may occur in young children, but also it hap- 
pens as a congenital affection ; between the two there are many 
gradations. Its origin is unknown, but since the disease appears 
in premature and weak children, some form of malnutrition is 
supposed to act as its basis. There are no known lesions except- 
ing the mysterious hardening of the skin and the equally myste- 
rious solidification of the subcutaneous fat. The disorder may 
involve a part or the whole of the surface. Usually it begins on 
the lower extremities, and then spreads upward ; it is only in the 
exceptional instances that it starts on the face and head, after 
which it involves the rest of the body. In the beginning the 
skin is pale, whitish, and of a cadaveric texture. Later on it 
takes on a bluish, somewhat cyanotic tint and also may be slightly 
icteric. The surface becomes progressively hard, thick, and un- 
pliable ; it cannot be indented by the finger, and the skin becomes 
so adherent that one cannot pick it up. Gradually a pseudo- 



INJURIES AND DISEASES OF THE NEW-BORN 



71 



anchylosis supervenes so that the jaws are sufficiently rigid to 
prevent nursing, and the joints become sufficiently stiff to make 
motion no more than partial. The temperature falls one, two, or 
three degrees below normal, the pulse is slow, and the respira- 
tion is weak, slow, and shallow. 

Congenital cases are usually still-born ; in the others the 
disease within a few days after birth usually ends in death. 
The older the child and the less general the involvement, the 
greater are the chances of recovery. Under all circumstances, 
however, the outlook is grave, since there is no treatment except 
keeping the infant warm in an incubator, and the most scrupulous 
attention to the general care. 



(Edema 

(Edema is a symptom, not a distinct disease, and may occur in 
any part of life. It is very liable to happen, in greater or less 
degree, in very young infants who suffer from cardiac disease, 
especially when the right heart is involved, in conditions of mal- 
nutrition, ansemia, and after loss of blood. There are no distinc- 
tive appearances that mark it off from the oedema of adults when 
they are free from disease of the kidney. The puffiness is first 
observed in the eyelids and feet, and may then extend to the legs, 
arms, and body. The diagnostic sign is the pitting on pressure 
and the presence of the concomitant nutritional, cardiac, and hsemic 
disturbances. 

Treatment is general : the infant must receive wise and good 
care, the body heat if abnormally low must be kept to or slightly 
above normal, and such drugs as heart stimulants with diuretics 
should be administered. If the oedema passes away, general 
tonics must be prescribed. 



CHAPTER VI 

FEEDING 

The standard food for infants is human milk, which is a secre- 
tion, not an exudation, from the mammary gland. It is a bluish 
white, sweet fluid, of an alkaline or neutral reaction, and an aver- 
age specific gravity of 1.031 at 15.5° C. (60° F.), the extremes 
being 1.027 and 1.032. The average composition according to a 
number of authorities, such as Konig, Pfeiffer, Leeds, Harrington, 
Forster, and Meigs, is 

Fat 3 to 4 

Sugar 6 to 7 _ 

Proteids 1 to 2 

Salts . . ' . . . . 0.1 to 0.2 

Total solids . . . . 13 to 12 

Water 87 to 88 

Specific gravity 1.028 to 1.034 

Reaction Alkaline or neutral 

While these figures represent the normal average, many varia- 
tions are possible even where the mothers are healthy and the 
children are well and increasing in weight. The very instructive 
table of analyses, made by Harrington, and quoted by Rotch, of 
fourteen specimens of human milk occurring under such circum- 
stances may be used as a demonstration : — 





Fat .... 




i 
5.15 

5.68 
4.14 
0.17 


II 

4.88 
6.20 
3.71 

0.19 


in 

4.84 

6.10 

4.17 

0.19 


IV 

4.37 
6.30 
3.27 
0.16 


V 

4.11 
5.90 
3.71 
0.21 


VI 

3.82 
5.70 
1.08 
0.20 


VII 

3.80 


Milk-sugar 
Proteids . . 
Ash ... . 




6.15 
3.53 
0.20 


Total solids 
Water . . 


15.15 

84.85 


14.98 
85.02 


15.30 
84.70 


14.10 
85.90 


13.93 
86.07 


10.80 
89.20 


13.68 
86.32 






100.00 


100.00 


100.00 


100.00 


100.00 


100.00 


100.00 



72 



FEEDING 



73 





VIII 


IX 


X 


XI 


XII 


XIII 


XIV 


Fat 


3.76 


3.30 


3.16 


2.96 


2.36 


2.09 


2.02 


Milk-sugar . . 


6.95 


7.30 


7.20 


5.78 


7.10 


6.70 


6.55 


Proteids . . . 


2.04 


3.07 


1.65 


1.91 


2.20 


1.38 


2.12 


Ash 


0.14 


0.12 


0.21 


0.12 


0.16 


0.15 


0.15 


Total solids . 


12.89 


13.79 


12.22 


10.77 


11.82 


10.32 


10.84 


Water . . . 


87.11 


86.21 


87.78 


89.23 


88.18 


89.68 


89.16 




100.00 


100.00 


100.00 


100.00 


100.00 


100.00 


100.00 



Colostrum, the milk secreted during the first two or three 
days after parturition, has, according to Pfeiffer, the following 
composition : — 

Specific gravity 1.040 to 1.046 

Fat 2.04 

Milk-sugar 3.74 

Proteids 5.71 

Ash 0.28 

Total solids 11.77 

Water . 88.23 

100.00 

It is a strongly alkaline, yellowish fluid, less sweet than ordinary 
mother's milk. It coagulates very easily in the presence of heat 
and sometimes spontaneously. It contains a variable but large 
number of granular bodies, called colostrum bodies, which are sup- 
posed to be degenerated epithelial cells. They are four or five 
times greater in size than the milk globules of a later period. 
The function of this fluid is in part nutritional and in part 
cathartic. 

The fat in human milk is a compound of stearin, palmatin and 
olein, made up in part of the glycerides of butyric, myristic, 
caproic, and caprylic acids. Its function seems to be threefold ; 
to conserve nutrition, to contribute to the reserve forces of the 
body, and to act as a cathartic. 

The proteids are in process of investigation, so that as yet 
one may not make a positive statement of their composition. 
Blythe states that they contain casein, an albumin, and peptone 
(galactin) ; Hammarsten gives casein, lacto-albumin and lacto- 
globulin. In all likelihood, the composition will be found to be 
even more complex. The casein is suspended in the body of the 



^^■HHH 



74 THE MEDICAL DISEASES OF CHILDHOOD 

fluid and is not dissolved. The quantity of albumenoids varies 
between very wide limits in the milk of different women, and of 
the same women in different conditions of health and functional 
activity. In colostrum and the milk of the first two weeks they 
exist in surprisingly large amounts. 

The mineral matters, ash or salts exist in large amount in the 
first two weeks ; after that they assume their regular proportion 
as shown above. They have an important nutritive and stimulat- 
ing function. The best analysis of their composition is that of 
Harrington which was made for Dr. Rotch. 

Calcium Phosphate 23.87 

Calcium Silicate 1.27 

Calcium Sulphate 2.25 

Calcium Carbonate 2.85 

Magnesium Carbonate 3.77 

Potassium Carbonate 23.47 

Potassium Sulphate 8.33 

Potassium Chloride 12.05 

Sodium Chloride 21.77 

Iron Oxide and Aluminum 0.37 

100.00 

The sugar, in contradistinction to the proteids, is not abun- 
dant during the first two weeks ; thereafter it begins to assume 
its permanent proportions which, once attained, undergo very little 
change. This element of the milk is more nearly constant than 
most of the other ingredients. It is both easy of digestion and 
valuable in nutrition. 

In those cases where the milk does not agree with the child 
or his development is unsatisfactory, an exact diagnostication of 
the trouble and an intelligent attempt to rectify it require a 
fairly accurate knowledge of the constituent parts of the food. 
The most thorough method is a full quantitative analysis. This, 
while not especially difficult, requires considerable technical 
knowledge, and the expenditure of more time than can usually 
be given to it. The necessity of obtaining approximately ac- 
curate results quickly and easily has brought about many good 
methods, some of which, while rapid enough, need special appa- 
ratus ; in this category we may place F. Soxhlet's excellent 
method. Some of the desired items are easily ascertained : thus 
the reaction may be ascertained by litmus paper. The quantity 



FEEDING 15 

may be roughly estimated by the amount obtained with a breast 
pump ; this is so inaccurate that better results will follow weigh- 
ing the child on a sensitive scales before and after several nursings. 
The specific gravity may be read off on any reliable hydrometer 
which has the necessary range. The sugar so rarely varies much 
from the normal limits that one assumes little risk in supposing 
it to be regularly constant. The same may be said of the in- 
organic salts, so that the remaining unknown factors are the fat 
and the proteids. The fat may be reckoned out by means of one 
of the various centrifugal machines, such as the Leffman & Beam 
or the Lister-Babcock. Another method is by the use of a cream- 
gauge, for instance that of Holt. This device is very simple and 
very often satisfactory ; but it must not be regarded as more 
than approximately exact. "The glass cylinder holding ten 
cubic centimetres is filled to the zero mark with freshly drawn 
milk. This is allowed to stand at the temperature of the room 
(66° to 72° F.) for twenty-four hours and the percentage of cream 
is then read off. Under these conditions, the relation of the 
percentage of cream to that of fat is very nearly as 5 to 3, 
thus 5 per cent of the cream will indicate that the milk contains 
3 per cent of fat, etc." Another procedure that is both rapid 
and simple, is the Werner-Schmidt method ; the apparatus re- 
quired is a test-tube, whose capacity is 50 cc. calibrated in cubic 
centimetres and tenths. Into this 10 cc. of milk and an equal 
amount of strong hydrochloric acid are poured ; the mixture is 
then boiled, being shaken from time to time, until it assumes a 
dark brown color. The tube with its contents is then cooled 
quickly by being plunged into water, after which a known quan- 
tity of ether, usually about 25 to 30 cc, is added, thus filling the 
tube to one of its marked divisions. The tube is then shaken for 
about half a minute to mix its contents and allowed to stand 
for about five minutes. The layer of ether is then read off, an 
aliquot part pipetted off, evaporated to diyness, and weighed. 
The process is very simple and pleasurably accurate. 

The proteids may be calculated in a general fashion from the 
known specific gravity and percentage of fat. Since we know 
that large amounts of proteids raise the specific gravity, and large 
amounts of fat lower it, the result naturally follows that a high 
specific gravity with a normal quantity of fat indicates a high 
proteid percentage ; and a high fat percentage with a high spe- 



76 THE MEDICAL DISEASES OF CHILDHOOD 

cific gravity means a markedly high proteid percentage. Other 
variations can easily be worked out. In making these tests, the 
middle portion of the milk should be used, since the fore-milk is 
richer in proteids and poorer in fats, while the after-milk or 
"strippings" is poorer in proteids and richer in fat than the 
whole quantity combined. 

In some cases a bacteriological examination may reveal the 
presence of staphylococcus pyogenes albus, s. pyogenes aureus, 
and streptococcus pyogenes. These, although present in small 
amounts, prevent the fluid from being considered sterile. It is 
supposed that the micro-organisms penetrate the nipple, and 
therefore are found in the first quantity withdrawn. 

The milk does not necessarily contain the same percentage of 
its ingredients at all times ; indeed, for various reasons, its com- 
position may vary considerably, so much so as to influence seri- 
ously the health of the child. Some causes, such as menstruation, 
passing indispositions, and repeated pregnancies, are commonly 
supposed to have a more direct importance than they really pos- 
sess. Others, such as disproportion between diet and exercise, 
disturbed mental conditions, and certain drugs, may have a very 
real bearing upon the case. These drugs are most apt to act 
when the nurse is debilitated, the milk poor in quality, or the 
child feeble. Those which are most sure to affect the infant are 
the saline cathartics, opium, and belladonna. The salicylates, the 
bromides, and the iodides are less certain in their effects, and the 
mercurial salts are only slightly liable to> be carried in the milk. 
The effect of disturbed mental conditions may be even greater 
than that of drugs ; this is especially apt to occur, and in the most 
pronounced form, in nervous, sensitive, and irritable women who 
undergo the shock of great sorrow, overwhelming elation, uncon- 
trollable attacks of temper, or even the pettier annoyances of daily 
life. In such cases the milk may become not only unfit for the 
child's nourishment, but also seemingly poisonous. 

The effects of diet upon the quality and quantity of milk is 
at times very great. A woman whose food is poor and not plen- 
tiful is apt to produce milk of a lowered fat percentage ; at the 
same time the proteids are deficient, normal, increased in amount, 
or changed in quality. If, in addition, she has hard work to do, 
the proteids are more apt to be lessened in quantity than other- 
wise. A largely nitrogenous diet has the tendency to increase 



FEEDING 



77 



both fats and proteids, especially if the amount of fluids consumed 
is not great and the woman's exercise is insufficient. A vegetable 
diet has, on the contrary, a tendency to diminish both fat and pro- 
teids. The effect of alcohol, especially in the form of beer, ale, 
porter, and stout, is not a constant one ; in some cases it may in- 
crease the quantity of proteids. A nurse who lives upon a rich 
diet and whose general life is lazy and sedentary is apt to produce 
a milk that is characterized by too much proteids and fats. 

These fats may be cast into a sort of therapeutic table like the 
following : — 



To increase proteids . 

To decrease proteids . 

To increase fat . 

To decrease fat . 

To increase total quantity 

To decrease total quantity 



decrease exercise and make diet rich, 
increase exercise and simplify diet, 
increase quantity of meat in diet, 
decrease quantity of meat in diet, 
increase total liquids in diet, 
decrease total liquids in diet. 



Under normal conditions the nursing should be arranged as 
follows : — 

From birth to the end of the first month, every two hours from 6 a.m. to mid- 
night. 

From the end of the first month to the middle of the third, every two and a half 
hours from 6 a. m. to 10.30 p. m. 

From the middle of the third month to the eighth month, every three hours 
from 6 a.m. to 9 p. m. 

From the eighth month to one year, every three and a half hours from 6 a. m. 
to 8 p. M. 

Substitute Feeding 

In the many cases where the mother is unable, for physical or 
mental reasons, to nurse her child, a substitute for her milk should 
be provided with as little delay as possible. The practice of waiting 
in the hopes of some indefinite improvement is apt to result in so 
pronounced a condition of malnutrition in the infant that months 
of earnest endeavor may be required to restore a fair amount of 
health. One of the first resources, fortunately not so common as 
in former times, is to secure a wet-nurse, who should be between 
twenty and thirty years of age, healthy, not fat, of good habits 
and character, whose child is healthy and of the same approximate 
age as the foster-child. The objections to the ordinary wet-nurse 
are, in most cases, weighty negations of these qualifications. Usually 
the woman comes from an unfavorable class, or from distinctly 



78 THE MEDICAL DISEASES OF CHILDHOOD 

unfavorable circumstances. The change from poverty and hard- 
ship to ease or even luxury is hard for her to bear. She is very 
liable to become lazy, to take insufficient exercise, to eat and drink 
unreasonably and inordinately ; she may even have had a personal 
history of syphilis or a family history of tuberculosis without 
being frank enough to acknowledge the fact. She realizes the 
strength of her position, becomes dictatorial and insubordinate, 
and interferes with the discipline of the household. Commonly 
she has vicious habits and vicious associates, and the influence 
upon the child is not for good. Her manner of life is apt to 
induce unfavorable conditions of the milk supply, and in many 
instances it is difficult to make her care for her charge in a thor- 
ough fashion. In spite of the parent's willingness to submit to 
her extravagances of conduct, frequent changes are inevitable ; 
and a succession of wet-nurses is tantamount to a succession of 
tribulations. I have endured so much unnecessary care, anxiety, 
and labor from these women that their value seems to me, at the 
best, doubtful. Nevertheless, if a healthy, well-mannered, and 
tractable woman can be secured, some of these objections may not 
hold good ; such a person is potentially very useful. Many prac- 
titioners prefer a wet-nurse to any other method of substitute 
feeding, and give as their reason that her milk is the natural food 
for a child, that it is what the mother herself would have given 
if she were able, and that by the close association between child 
and nurse an intimate bond of interest and affection may arise 
that must necessarily result in advantage to the baby. As a mat- 
ter of theory this is excellent ; and if the practical results were 
in any way commensurate with the favorable statement of her 
expected virtues, there would be no doubt of what the best method 
of substitute feeding is. Unfortunately the demands of the situ- 
ation are considerable, and a woman must really be a fairly supe- 
rior person to fulfil them. Such a person is hard to find, and 
according to common report it is becoming harder and harder to 
find her. The main trouble lies in the discrepancy between her 
theoretical value and her actual efficiency. 

With the wet-nurse out of the way, the problem consists in 
adapting the milk of a domestic animal for the digestive and 
assimilative capacities of a human infant. The choice may be 
made from the milk of the mare, the ass, the goat, and the cow. 
The respective analyses are, according to Blythe, as follows : — 



FEEDING 



79 



Make's Milk 



Fat . 

Sugar 

Proteids . 

Ash . 
Total solids 
Water . 



100.00 



Ass's Milk 



Fat . 

Sugar 

Proteids . 

Ash . 

Total solids 
Water . 



1.02 

5.50 
1.89 
0.42 
8.83 
91.17 
100.00 



G 


oat's Milk 


Fat . 


. 


Sugar 


. 


Proteids . 


. 


Ash . 


. 


Total solids 


. 


Water . 


, 



100.00 



Cow's Milk 
Average (G. E. Gordon's Compilation) 



Fat . 


. 3.50 


Sugar 


. 4.30 


Proteids . 


. 4.00 


Ash . 


. 0.70 


Total solids . 


. 13.00 


Water . 


. 87.00 




100.00 


Specific gravity . 


. 1.029 to 1.033 


Reaction . 


Slightly acid 



The different breeds of cows, such as the Jersey, Durham, 
Bretonne, Ayrshire, Holstein, Holstein-Friesian, and the various 
American strains, have each their peculiarities ; but besides being 
not radically dissimilar, they come to us mixed, as in the common 
dairy product. Moreover, we have very little assurance that, if 
we wished for the milk of a particular breed, our wish would be 
respected. The responsibility would be more than the ordinary 
dairy conscience is supposed to withstand. The greatest measure 
of safety and satisfaction is to be obtained from the collective 
milk of a general well-kept herd. 

While the milk of all these different animals may be used for 
infant-feeding, the only one that produces a large enough quantity 
to supply the demand is the cow. At almost regular intervals 
plans to collect sufficient herds of goats or mares or asses are 
formed, with the idea of substituting their milk for that of the 
cow. Hitherto, on account of the great cost and the small amount 
of milk obtained, each one has ended in failure. The mere 
fact that the ass produces no more than one and one-quarter 
litres of milk per day is enough to demonstrate the futility of 
these efforts. Nevertheless, in spite of the satisfactory quantity 
of the cow's milk, the quality leaves something to be desired. 
The differences consist in the greater amount of inorganic salts, 



SO THE MEDICAL DISEASES OF CHILDHOOD 

especially phosphate of calcium, and the equal excess of proteids 
in cow's milk. In addition, these proteids vary in quality, having 
much more casein than lactalbumin, while in human milk the 
reverse is true. There is twice as much coagulation of the 
albumenoids in cow's as in human milk, and the curd is much 
harder and more tenacious. 

In preparing cow's milk for an infant's use, the tendency in 
these days is in the direction of modification — of such manipula- 
tion as will make the cow's milk the approximate equivalent of 
the human secretion, or in case of weak and delicate children of 
attenuating it to such a degree that the work of digestion is 
appropriately lessened. The main difficulty resides in the modi- 
fication of the proteids, which ought commonly to be reduced 
below the level of the percentage in the human milk ; and then 
as the child shows ability to digest the food, we may increase the 
quantity to the normal limit. In the beginning the wisest plan 
in practically all cases is to give a small proportion of albumenoids 
largely diluted rather than a more concentrated mixture. Thus 
it is commonly wiser to begin with less than one per cent instead 
of more. The dilution is naturally made by the addition of water. 

The element of fat does not usually give as much difficulty as 
the proteids. It exists in the cream, which is no more than milk 
with a large percentage of fat. In the less rich specimens the 
other ingredients are almost the same as in ordinary milk ; and it is 
only in the richest that these ingredients are noticeably — and even 
then only to a moderate degree — reduced. The ordinary cream 
that results from the effect of gravity when the milk is allowed to 
stand is equivalent to sixteen per cent. By the use of a centrifugal 
machine a forty per cent cream may be obtained or any degree less. 
Since an eight per cent or twelve per cent cream is most useful in 
modification, one of them is generally selected for this purpose ; 
and they may readily be obtained by placing a jar of milk on ice 
for five hours when the lighter cream will be formed, or for six 
hours when the heavier will be prepared. It is estimated that 
one quart of milk produces two and five-tenths grammes of the 
former and one and five-tenths grammes of the latter. In modi- 
fication it is best, as with the proteids, to begin with a small quan- 
tity and gradually to approximate to the normal. The cream may 
be separated by decanting or drawing off the milk through a siphon. 

The percentage of sugar may be put at or near the normal in 



FEEDIXG 81 

comparatively early infancy ; milk-sugar is used for this purpose, 
since it exists in normal human milk, and in addition it has a 
lesser tendency to undergo fermentation than cane-sugar. The 
fact that it is not so sweet has little bearing upon the matter, 
since the function of this ingredient is rather one of supplying 
nutrition than of creating a sweet taste. It is usually employed 
in the dry state or in a filtered solution of from five to twenty per 
cent, which should be made anew each day. The mineral salts, 
being relatively of the same excess as the albumenoids, are reduced 
to their proper amount when the proteids are diluted. The reac- 
tion may, of course, be influenced by the addition of an alkali, the 
usual one being lime water. About four or five per cent will satisfy 
the requirements. It is supposed that the milk used for modifi- 
cation is as clean and as pure as the best care will provide. The 
cow's udders, the utensils, and the hands and clothes of the dairy- 
men must be thoroughly clean ; and in cases of doubt the fluid 
may be filtered through absorbent cotton, although a small part 
of the fat may thus be lost. 

A convenient, rapid, and ingenious method of combining these 
ingredients is that published by Holt. He uses the 12 per cent 
and the 8 per cent creams mixed with various quantities of suit- 
able sugar solutions, as in the following formulas : — 

1. To make 2 per cent fat, 6 per cent sugar, and 0.60 per cent 
proteids, use one part of 12 per cent cream and five parts of 6 per 
cent sugar solution. 

2. To make 2.5 per cent fat, 6 per cent sugar, and 0.8 per cent 
proteid, use one part of 12 per cent cream and four parts of 6 per 
cent sugar solution. 

3. To make 3 per cent fat, 6 per cent sugar, and 1 per cent 
proteids, use one part of 12 per cent cream with three parts of 7 
per cent sugar solution. 

4. To make 3.5 per cent fat, 6 per cent sugar, and 1.2 per 
cent proteids, use one part of 12 per cent cream with two and one- 
half parts of 7 per cent sugar solution. 

5. To make 4 per cent fat, 6 per cent sugar, and 1.3 per cent 
proteids, use one part of 12 per cent cream with two parts of 7 
per cent sugar solution. " In all these formulas it will be seen 
that the ratio of the fat to the proteids is 3 to 1. Not only 
these formulas, but any intermediate ones with this ratio may be 
derived by varying the dilution. The sugar may be easily modi- 



■i^gMM 



82 THE MEDICAL DISEASES OF CHILDHOOD 

fiecl, if desired, by using weaker or stronger solutions than those 
mentioned." 

A more concentrated or more attenuated milk mixture may 
be made by using the 8 per cent cream. 

6. To make 4 per cent fat, 7 per cent sugar, and 2 per cent 
proteids, use equal parts of 8 per cent cream and 10 per cent 
sugar solution. 

7. To make 3 per cent fat, 6 per cent sugar, and 1.5 per cent 
proteids, use one part of 8 per cent cream with one and one-half 
parts of 7 per cent sugar solution. 

8. To make 2 per cent fat, 6 per cent sugar, and 1 per cent 
proteids, use one part of 8 per cent cream with three parts of 
7 per cent sugar solution. 

9. To make 1 per cent fat, 5 per cent sugar, and 0.5 per cent 
proteids, use one part of 8 per cent cream with seven parts of 5 per 
cent sugar solution. Other formulae in which the fat and proteids 
stand in the relation of 2 to 1 can easily be reckoned out by the 
quoted method. 

Formulas giving small fat percentages may be filled by using 
plain milk instead of cream. 

10. To make 1.8 per cent fat, 6 per cent sugar, and 2 per cent 
proteids, use equal parts of plain milk and 8 per cent sugar solution. 

11. To make 0.9 per cent fat, 5 per cent sugar, and 1 per cent 
proteids, use one part of plain milk with three parts of 5 per cent 
sugar solution. 

12. To make 0.45 per cent fat, 4 per, cent sugar, and 0.50 per 
cent proteids, use one part of plain milk with seven parts of 4 per 
cent sugar solution. 

13. To make 0.30 per cent fat, 4 per cent sugar, and 0.34 per 
cent proteids, use one part of plain milk with eleven parts of 

4 per cent sugar solution. 

The reckoning of the separate quantities that correspond to 
these proportions is a simple matter of arithmetic which hardly 
justifies elaboration. Allowance must be made for the lime water 
that is necessary to give the required alkaline reaction. Since 

5 per cent of this ingredient is called for, the corresponding quan- 
tity must replace an equal amount of the boiling water in which 
the milk-sugar is dissolved. The process of combining is simple 
and rapid ; the ascertained quantity of boiling water minus the 
bulk of lime water is to be mixed with the milk-suofar and strained 



FEEDING 83 

through filter-paper, or aseptic absorbent cotton. The cream or 
milk and lime water are then added, and the whole mixture is well 
shaken and divided into the required number of bottles. These 
are immediately to be closed with plugs of aseptic absorbent 
cotton, chilled, and put in an ice-chest. 

A simple method of modifying milk at home has been devised 
by Baner. It certainly has the merits of easy manipulation and 
plainness of statement. He has reduced the relation of the com- 
ponent parts of milk to the form of equations, and by arranging 
them he arrives at his result. His method is "based on the 
understanding that good cow's milk contains on the average 4 per 
cent of fat, 4 per cent of proteids, thus regarding cream as simply 
a superfatted milk, containing practically the same amount of pro- 
teids as milk itself. So long as the cream is fresh and clean we 
may use either a 12 per cent cream, obtained by allowing milk to 
stand over ice in a tall vessel for six hours, and removing the upper 
fifth ; a 16 per cent cream, obtained by skimming, or a 20 per cent 
cream obtained by the separator. 

Given : Quantity desired (in ounces) = Q 
Desired percentage of fat = F 

Desired percentage of sugar = S 
Desired percentage of proteids = P 

To find (in ounces) : 

Cream (16 per cent) = — x (F — P) 

Milk = Q-*-I _ C 

4 

Water = Q - (C + M) 

Dry milk-sugar = (S - P) x Q 

J ° 100 

If 20 per cent centrifugal cream is used, the denominator of 
the cream formula will be 16 instead of 12. If 12 per cent 
cream is used, it will be 8 instead of 12. 

Example. — Suppose we want 40 oz. of a mixture to con- 
tain 4 per cent of fat, 7 per cent of sugar, and 2 per cent of 

proteids : — 40 

Cream = — x 2 = 6f oz. 
12 3 

Milk = ^xZ _ 6 2 = 13 i OZo 

4 
Water = 40 - 20 = 20 oz. 

Sugar =^ii° = 2oz. 
* 100 



84 THE MEDICAL DISEASES OF CHILDHOOD 

An apparatus has recently been devised for the home-modifica- 
tion of milk and was presented before the New York Academy of 
Medicine, by Dr. L. Emmett Holt, in January, 1899. It is 
a seven-panelled glass jar upon the various faces of which are 
marks which indicate quantity of the constituent parts of the 
milk. It is called the " Materna " milk modifying apparatus. 

In November, 1899, Dr. H. D. Chapin of New York reported 
yet another method of home modification of milk. The following 
quotation is from his paper and gives his plan in full : " By mix- 
ing cream and skimmed milk, as it were in situ, in certain propor- 
tions, there is a certain relation between the fats and proteids 
that may be used in feeding the infant. In the home modification 
of milk by means of this bottled milk, the cream is readily and 
accurately separated from the under milk by means of a dipper 
measuring exactly one fluid ounce. Quart milk bottles all have 
substantially the same kind of neck, and the dipper has been made 
to easily fit into any of these bottles, after an inspection of a large 
number. The very top layer of cream is taken off with a tea- 
spoon, and the dipper thus filled and the first ounce removed ; 
otherwise the milk would spill over when the dipper is let down. 
The successive ounces of cream are then easily removed without 
jarring, siphoning, or other manipulation. While it is not easy 
to test the proteids in milk, we are taught on good authority that 
they nearly equal the fat in milks up to four and a half per cent 
fat. Avoiding small fractions, cream with 12 per cent fat would 
have three times as much fat as proteids (12 per cent fat and 4 
per cent proteids) ; ten-per-cent cream would have two times and 
a half as much fat as proteids (ten per cent fat and four per cent 
proteids) ; eight-per-cent cream would have twice as much fat as 
proteids (eight per cent fat and four per cent proteids); six-per- 
cent cream would have one time and a half as much fat as pro- 
teids (six per cent fat and four per cent proteids). Almost any 
desired percentage of fat or proteids can be procured by diluting 
these creams, using the cream that contains the desired ratio be- 
tween fat and proteids. Having at hand a bottle of milk which 
has separated into two layers, one very rich in fat and the other 
very poor in fat, the problem of getting a cream of any desired 
percentage of fat consists in mixing the very rich milk with 
enough poor milk to reduce its percentage of fat to the point de- 
sired. In practice, cream containing twelve per cent and eight 



FEEDING 85 

per cent fat are most useful. If it were possible completely to 
separate the fat for a quart of four-per-cent-fat milk, nearly eleven 
fluid ounces of twelve-per-cent-fat cream could be had, or sixteen 
fluid ounces of eight-per-cent-fat cream. In the 'deep-setting' 
process of creaming, about ten per cent of the total fat is left in 
the skimmed milk, so we would naturally expect to get only nine- 
tenths of the theoretical quantity of fat in the creamy layer. In 
practice, where it is desired to have fat three times the proteids, 
make a twelve-per-cent-fat cream by taking the first nine dippers 
of cream and milk from a quart bottle on which the cream has 
risen . . . and mix. Result, nine fluid ounces cream — about 
twelve fat, four per cent proteids, four per cent sugar. What is 
not needed of the nine fluid ounces can be put back into the 
bottle. For any quantity of food containing fat three times the 
proteids, use this formula with twelve-per-cent cream : — 

" Dilution of twelve-per-cent cream = twelve per cent divided 
by desired percentage of fat. 

" Fluid ounces twelve-per-cent cream = desired fluid ounces food 
divided by dilution. 

" Sugar = desired fluid ounces food divided by twenty. 

" Diluent = desired fluid ounces food minus fluid ounces 
twelve-per-cent cream. 

" Example. — Desired twenty-four fluid ounces containing fat, 
three per cent ; proteids, one per cent ; sugar, six per cent. 

" Twelve per cent -f- three per cent = four dilution. 

" Twenty-four -r- four = six fluid ounces twelve-per-cent cream. 

" Twenty-four -4- twenty = one ounce and a fifth sugar. 

" Twenty-four — six = eighteen fluid ounces diluent. 

" When it is desired to have fat two times the proteids, take 
the first sixteen dipperfuls of cream and milk out of a quart bot- 
tle and mix. Result, sixteen fluid ounces cream — about eight 
per cent fat, four per cent proteids, five per cent sugar. What is 
not needed of the sixteen ounces can be put back in the bottle. 
For any quantity of food containing fat two times the proteids, 
use this formula with eight-per-cent cream : — 

" Dilution of eight-per-cent cream = eight per cent divided by 
desired percentage of fat. 

" Fluid ounces eight-per-cent cream = desired fluid ounces di- 
vided by dilution. 

" Sugar = desired fluid ounces food divided by twenty. 



86 THE MEDICAL DISEASES OF CHILDHOOD 

" Diluent — desired fluid ounces food minus fluid ounces eight- 
per-cent cream. 

" Example. — Desired forty fluid ounces food containing fat, 
four per cent ; proteids, two per cent ; sugar, seven per cent. 

" Eight per cent -s- four per cent = two dilution. 

" Forty -s- two = twenty fluid ounces eight-per-cent cream. 

" Forty -r- twenty = two ounces sugar. 

" Forty — twenty = twenty ounces diluent." 

This work of adapting cow's milk to the needs of a young 
child, especially a weak or ailing one, is most accurately done in 
the so-called milk laboratories which have been recently instituted 
through the initiative of Dr. T. M. Rotch of Boston. The un- 
doubted advance in infant-feeding which the enterprise has accom- 
plished is of the greatest possible value, for it has changed the 
preparation of the food from a matter of guesswork, to one of 
commendable certainty. The ingredients which they commonly 
use are a 20 per cent milk-sugar solution, a 16 per cent fat, and 
a " separated " milk from which the cream has been removed by 
a centrifugal machine. The one objection to the centrifugalizing 
process is the liability which the violent motion has to break up 
the fat-globules with the resulting formation on the surface, when 
the milk is heated, of a layer of oil. Some chemists believe that 
this method of separating and recombining the elements of milk 
does not permit of a suitable mixture, that especially the fatty 
portion is in a poor state of emulsion. While the same, or similar 
objections can be urged against any artificial combination, the 
main fact holds good that a properly modified milk represents the 
best manufactured infant's food which is at our command. 

The fact that milk is usually not sterile suggests to the physi- 
cian the possibility of infecting a healthy child, while attempting 
to nourish him, with a serious disease, such as tuberculosis, diph- 
theria, enteric fever, scarlet fever, and many gastro-intestinal dis- 
orders. To reduce this danger the oldest plan was to boil the 
milk. This was found to make it sterile, but at the same time 
the physiological character of the food was so much changed that 
a large proportion of infants could not digest it. The situation 
therefore changed from the dangers of infection to those of equally 
grave malnutrition. When this was fully recognized a change was 
made to the process of sterilization, the continued heating at a 
temperature of 100° C. (212° F.) for an hour and a half. The 



FEEDIXG- 87 

pathogenic micro-organisms were thereby destroyed, although 
their spores were not. At the same time, as was later on ascer- 
tained, the value of the milk itself was seriously affected. The 
children thus fed, instead of being afflicted with microgenic dis- 
orders, suffered from constipation, scurvy, and disturbances of 
nutrition that were equally noteworthy. An examination of the 
milk showed that the lactalbumin was sufficiently coagulable, that 
the fat-globules lost their individuality and became blended with 
each other and the insoluble albuminous matter, that the sugar 
was injured, and that in general the quality of the food became 
lowered. To obviate these disadvantages the plan of partial 
sterilization, called pasteurizing or heating the milk at a tem- 
perature of 75° C. (167° F.) for twenty minutes, was devised. 
This was also found to destroy most pathogenic germs, although 
the spores were less affected than in sterilization. A feeling has 
been steadily growing that pasteurized milk is open to similar 
objections as those produced by the more prolonged heating ; and 
while in many circumstances some such procedure is at present 
desirable, since the milk sold by even the better class of dairymen 
is far from clean, the rational and most desirable protection comes 
from such rigorous asepsis in the collection and handling of milk 
that any form of sterilization will be unnecessary. 

It is doubtful whether absolute asepsis is practically possible; 
and likewise it is doubtful whether it is necessary. We all 
know that within a few hours after birth the gastro-intestinal 
contents give cultures of various micro-organisms; and in addi- 
tion, many samples of breast-milk have been shown to be non- 
sterile. The main indication for preventing disease is the adoption 
of such measures of cleanliness as will prevent contamination of 
the milk by too great a number of bacteria, and, most of all, to 
exclude those specific germs that are communicated by direct 
or indirect contact with the well-known diseases. This can 
unquestionably be done by rigid cleanliness, in which every farm- 
hand must be conscientiously instructed. In this work the 
physician has as large a responsibility as the dairyman. 

After the milk has been prepared it must be divided into as 
many bottles as there are feedings in the twenty-four hours, 
thereby obviating one source of infection in filling a bottle when- 
ever the time for feeding has arrived. This may be easily ar- 
ranged each morning according to the schedule appended. 



88 



THE MEDICAL DISEASES OF CHILDHOOD 



Scheme for Feeding, with Intervals and Quantities 
During First Year 



















Intervals 












BETWEEN 

Feedings 


Amount in Each Bottle 


Feedings 
Per Day 


Total Amount Per Day 


1 wk. 


2 


hours 


30 gram. 


(1 oz.) 


10 


300 gram. (10 oz.) 


2 wks. 


2 


hours 


45 gram. 


(1* oz.) 


10 


450 gram. (15 oz.) 


3 wks. 


2 


hours 


60 gram. 


(2 oz.) 


10 


600 gram. (20 oz.) 


2 mos. 


2 


hours 


75 gram. 


(2* oz.) 


10 


750 gram. (25 oz.) 


1\ mos. 


2* 


hours 


90 gram. 


(3 oz.) 


9 


810 gram. (27 oz.) 


3 mos. 


2* 


hours 


105 gram. 


(8} oz.) 


8 


840 gram. (28 oz.) 


4 mos. 


3 


hours 


124 gram. 


(4i oz.) 


7 


868 gram. (29 oz.) 


5 mos. 


3 


hours 


135 gram. 


(4J oz.) 


7 


945 gram. (31 J oz.) 


6 mos. 


3 


hours 


165 gram. 


m oz.) 


6 


990 gram. (33 oz.) 


7 mos. 


3 


hours 


195 gram. 


(6J oz.) 


6 


1170 gram. (39 oz.) 


8 mos. 


H 


hours 


210 gram. 


(7 oz.) 


6 


1260 gram. (42 oz.) 


9 mos. 


3| 


hours 


210 gram. 


(7 oz.) 


6 


1260 gram. (42 oz.) 


10 mos. 


H 


hours 


255 gram. 


(8i oz.) 


5 


1275 gram. (42£ oz.) 


11 mos. 


H 


hours 


264 gram. 


(8f oz.) 


5 


1320 gram. (44 oz.) 


12 mos. 


H 


hours 


270 gram. 


(9 oz.) 


5 


1350 gram. (45 oz.) 



It must be kept in mind that such a plan is general and that 
there must be exceptions to it. The weight of the child has 
almost as much to do with the amount of food, the intervals be- 
tween the feedings, and the chemical composition, as his age. 
Thus, an infant of live months who has the size, weight, and de- 
velopment of one of three must be regarded as being less than five 
months. A hard and fast rule must not take the place of judg- 
ment and individual consideration. 

The care of the bottles and rubber nipples is a matter of the 
first importance, for on their cleanliness depends, to a large extent, 
the freedom from infection. In selecting them the ease with 
which they can be kept clean is always the deciding factor. For 
this reason the plain cylindrical bottles are the best, and if they are 
graduated, the measuring of the desired quantity becomes simple. 
The nipple should be made of soft black rubber, cone-shaped like 
a " dunce's cap," and having an aperture that is not too large. 
The bottles must be thoroughly scrubbed directly after being used, 
scalded, and then put in a solution of borax or washing soda. Be- 
fore being again used they must be thoroughly rinsed. The nip- 



FEEDING 89 

pies after being used must be scrubbed on both sides with a brush, 
scalded, and then kept in the borax or soda solution. Before being 
put on the bottle they also must be rinsed. When the bottle is 
filled for nursing, it must be properly heated by being placed in 
hot water. Besides the regularity of feeding, the process should 
be uninterrupted, should cover from twelve to fifteen minutes, and 
must receive the active attention of the mother or nurse. The child 
should recline in the attendant's arms, and the bottle must be 
held, rather than be propped up by pillows, in order to regulate 
the flow of food and exclude air from the nipple. If a portion of 
food remains in the bottle, it must not be warmed over for a 
second feeding, but should be thrown away. 

If these recommendations concerning feeding are not followed 
by an increase in weight and the development of a quiet, happy 
general condition, the physician must examine the symptoms to 
see whether the milk is faulty, and thereby get at the root of the 
trouble. One of the commonest errors is an excess of proteids, 
which is indicated by constipation or diarrhoea, vomiting of curdy 
masses, colic, or the presence in the faeces of undigested curds. In 
these cases either the proportion of the albumenoids, or the abso- 
lute amount due to excessive quantit} r of milk, or both, may be too 
great. Both should be reduced, and after toleration is established 
they may gradually be brought up to their permissible limit. In 
other cases there may be an excess of fat, followed by too great a 
number of stools, by the presence of masses of fat in the faeces, 
vomiting regurgitation of food after nursing, or by colic. On the 
other hand, a deficiency of fat will commonly cause constipation 
and hardening of the faeces. In still other instances the quantity 
of sugar may be too small. The consequence may be the produc- 
tion of gastric and intestinal fermentation, regurgitation or vomit- 
ing, an excess of movements which are foul-smelling, thin, acrid, 
and of abnormal color. If the milk is unduly attenuated in all 
or most of its constituents, there will be deficient weight and 
development. In most cases, by carefully following such indica- 
tions, one can discover in a very short time both the cause of the 
child's disorder and the indicated remedy. The children that 
will in all likelihood give most trouble are the very delicate ones 
whose digestive capabilities are feeble. From the first they suffer 
from all the symptoms of intestinal derangement, although the 
food has been very carefully prepared. Under these circumstances 



90 THE MEDICAL DISEASES OF CHILDHOOD 

the reduction of the ingredients, especially the proteids, must be 
immediate and sufficient. The albumenoids may be decreased 
until they are no more than one per cent or even a fraction 
thereof ; the fats may also be decreased, but not often to as low 
a point. No more particular rules can well be formulated ; each 
case must be carefully considered, and the changes may have to 
follow each other in rapid and wearying order. For the nagging 
assimilative abilities of a delicate child seem to have peculiar 
idiosyncrasies and fluctuations that must be patiently and tire- 
lessly followed. Occasionally a partial peptonization of the milk, 
after it has been modified, will give relief ; but it must be remem- 
bered that this device is of temporary value and may not be 
continued for a long time. In other cases the stimulating prop- 
erties of beef juice, especially where the indications call for a 
very small percentage of proteids, may give some aid when added 
in amounts of eight to sixteen grammes (one-quarter to one-half 
ounce). But no surer rule can be made than the one of consist- 
ently adapting the food to the expressed symptoms until relief 
has been obtained. When toleration has once been established, 
the gradual development of the nourishment to a normal com- 
position and amount is often no more than a matter of intelligent 
patience. 

Infant Foods 

A very large and increasing number of these foods are on the 
market, and although they have many faults, nevertheless their 
ease of preparation and cheapness retain for them a large popu- 
larity. If it were possible to make an artificial food that imitated 
very closely the composition and physiological structure of human 
milk, its production would undoubtedly be of great value. So 
far this has not been done, although the foods which are commonly 
employed could be replaced by products which are superior to 
those now sold. The Liebig foods, such as Horlick's food, Mel- 
lin's food, malted milk, Hawley's food, represent a combination of 
flours which has been treated with diastase until the starch has 
been converted into maltose and dextrin. The milk foods, such 
as Nestle's, the various Swiss foods and Gerber's food represent 
condensed milk which has been sweetened and supplemented with 
dextrinized flour. The farinaceous foods, such as Ridge's food, 
Imperial Granum, Robinson's Patent Barley, Hubbell's Prepared 



FEEDING 



91 



Wheat, usually consist of combined flours whose starch is partly 
changed into sugar. Carnrick's soluble food consists for the most 
part of carbohydrates; Lacto-preparata has about the same compo- 
sition, but in it milk-sugar replaces a portion of the starch. Lac- 
tated food is composed mostly of carbohydrates. The Peptogenic 
Milk Powder of Fairchild consists of pancreatin, lactose and 
alkaline milk salts. The condensed milks represent ordinary 
cow's milk which has been evaporated in vacuo, sterilized, and 
sweetened with cane-sugar. The unsweetened variety can also 
be obtained. 

The best way to examine these foods is to compare them, when 
prepared for use, to normal milk, as in the compilation made by 
Holt : — 





H 
■x. 

< 
63 

M 
Per 


2 

JX> 

o 
D 


35 c 
z a 

£ ^ 


~z 

s 


Malted Milk 


o 
o 
fa 

ai 

♦'a 

m 


fa 

m 
"« 
O 
O 


3m 


a 

Is 

32 




Per 


Per 


Per 


Per 


Per 


Per 


Per 


Per 




cent 


cent 


cent 


cent 


cent 


cent 


cent 


cent 


cent 


Fat 


4.00 


3.50 


0.99 


0.04 


0.39 


0.76 


0.16 


0.14 


1.12 


Proteids 


1.50 


4.00 


1.20 


1.50 


2.28 


1.54 


1.67 


1.98 


1.35 


Soluble carbohydrates 


7.00 


4.30 


7.23 


11.56 


10.18 


6.38 


0.41 


0.25 


4.06 


(sugars) 




















Insoluble carbohydrates 












4.19 


10.91 


10.65 


5.61 


(starch) 




















Inorganic salts 


0.20 


0.70 


0.17 


0.45 


0.50 


0.24 


0.07 


0.06 


0.56 


Water 


87.30 


87.50 


90.41 


86.45 


86.65 


86.89 


86.78 


86.92 


87.30 



A special mention should be made of the Gaertner mother- 
milk, which is cow's milk that has been so treated in a cen- 
trifugal machine that one half of its casein, sugar, and inorganic 
salts has been removed. The needed quantity of sugar must 
naturally then be added. The resulting percentage of fat is 3.1, 
and that of casein is 1.7. The manufacturers claim that the pro- 
cess eliminates bacteria and dirt, thus making a physiological 
sterilization. 



The Caee of Peematuee Ixfaxts. 

The task of rearing a child that is born before term, involves 
the application of artificial heat, protection from exposure, and the 



92 THE MEDICAL DISEASES OF CHILDHOOD 

suitable regulation of the food. Such children may weigh as 
little as two pounds, and in addition are usually undersized ; they 
are extremely weak, flabby, without enough vitality to suck or to 
breathe in a regular and sufficient manner. The pulse is very 
small, weak, rapid, and often irregular ; the cry is weak, the gen- 
eral condition is one of apathy, and the temperature is commonly 
subnormal. 

Children who are premature by one month only may be well 
protected by an oil inunction of the body which is to be followed 
by a swathing in cotton batting. About the buttocks and geni- 
tals absorbent cotton may be tucked, thus doing away with the 
necessity of using diapers, which are very apt to cause excoria- 
tions. Blankets may be wrapped outside of the cotton, and hot 
water bottles should be placed about the legs and body. These 
children instead of being washed may be cleaned with sweet oil, 
in much the same fashion as before soap was invented. 

Feeding should be accomplished by means of a large medicine 
dropper that is made for the purpose. Breast milk is best, but 
lacking it a properly modified milk should be substituted. The 
intervals between feeding should be reduced to one and a half 
hours. 

When the child is under eight months, an incubator will in all 
likelihood be required. One of the best of the elaborate types is 
that of Rotch, and almost every instrument maker has one or more 
specimens of his own. The simpler types are easily made by any 
one who has a fair amount of mechanical ingenuity. The require- 
ments consist of a glass-covered box in which there is a bed made 
up of cotton batting or absorbent cotton. Underneath is a cham- 
ber containing hot water, the heat of which is maintained by gas, 
alcohol, or oil flame. A thermometer for registering the temper- 
ature is placed inside, and in the walls are apertures for ventila- 
tion. A desirable amount of dampness in the atmosphere is 
maintained by means of a wet sponge. Naturally the glass lid is 
movable so that the child may be reached for purposes of manip- 
ulation, cleaning, and feeding. The cleaning is done with oil, 
not water. The food is administered at intervals of an hour or 
hour and a half by means of a large medicine dropper or a tube 
which has been passed into the stomach (gavage). The length 
of the residence in the incubator depends upon the child's devel- 
opment and vitality. 



FEEDING 93 



Weaning 



A child, under ordinary circumstances, should be weaned when 
he is one year of age, and the process should be a gradual rather 
than a sudden one, to avoid the dangers of gastric and intestinal 
derangements that are apt to follow an abrupt transition from one 
to another sort of food. Under some circumstances, such as preg- 
nancy, wearing out of milk supply, or acute sickness of the mother, 
the change may have to be made at some time previous to that 
stated ; and if these conditions arise, there should not be too long 
a delay with a consequent impoverishment of the infant's vitality. 
In some cases of acute sickness, where the necessity of the artifi- 
cial food is no more than temporary, the milk may be prevented 
from drying up by the consistent use of the breast-pump. On the 
other hand, when the normal nursing period closes, in the latter 
half or at the end of the summer, the child may be kept at the 
breast, supposing that the quality and quantity of the milk are 
sufficient, for a short additional period, in order to reduce the 
dangers of infection, that are greatest during hot weather. This 
prolongation of breast-feeding must be made with the full knowl- 
edge that the quality of milk is apt to deteriorate, as well as the 
fact that in the beginning of the second year the diet normally 
calls for a food composition and food bulk which human milk can- 
not supply. In some cases, where the robustness of the child is 
not quite complete, a course of mixed feeding may be advised ; 
while this has some advantages, the objections are very apt to be 
weighty. For in many instances the mother's milk is not only 
deficient but also unstable, and the attempt to compensate with 
an artificial mixture will involve a burdensome frequency of 
analysis of the mother's milk, and an undesirable frequency of 
change in the artificial food, in the attempt to maintain an equi- 
librium. 

Feeding During the Second Year and its Continuance 

During this period the foundation of the food must be good, 
wholesome milk. Many robust children are able to digest it in 
its undiluted form. If a difficulty exists, it is, as a rule, on account 
of the excessive quantity of proteids which may need no more than 
a trivial reduction. A o-ood formula for the first two months is 



94 THE MEDICAL DISEASES OF CHILDHOOD 

Milk 540 grammes (18 oz.) 

Cream (12 per cent) 115 grammes (3f oz.) 

Boiled Water 270 grammes (9 oz.) 

Milk Sugar 120-150 grammes (4-5 oz.) 

This will make about one quart of milk. From the fourteenth or 
fifteenth month the child should be able to digest plain milk. An 
additional element of food may be supplied in the form of various 
cereals which have been reduced to a thin gruel or jelly, strained, 
and mixed with milk. Clear soups may form an occasional meal, 
and baked apples, stewed prunes, and orange juice are eagerly re- 
ceived and well borne. A piece of zwieback, well toasted stale 
wheat bread, or toasted biscuit dipped in milk may be added to 
the soup or milk. When the child has shown his ability to digest 
these articles, he may, in addition, receive poached or soft-boiled 
eggs, rare scraped beef, and stale bread ; very often he may derive 
satisfaction and some benefit from being allowed to pick shreds of 
meat from the bone of a lamb chop from which the bulk of the 
meat has been cut. In the second half of the year it is unneces- 
sary to strain the cereals as it was before that time. 

From the third year the diet may be very much enlarged, and 
includes milk and cream, meat broths and soups, zwieback, toast, 
stale bread, biscuits (crackers), poached and soft-boiled eggs, 
broiled beefsteak and lamb chops, roast beef and lamb, underdone 
mutton, roast or fricasse chicken (preferably the white meat), 
boiled or broiled fish, especially those which are not too fatty. In 
the way of vegetables, one may use baked or creamed potatoes, 
spinach, asparagus tops, fresh peas and string beans, young and 
tender carrots. Stale bread, biscuits, and zwieback may of course 
be given every day, as likewise may all the cereals which must be 
well cooked. For dessert, the child may have plain rice pudding, 
custards, junket, clear jellies, apple sauce, stewed prunes, oranges, 
and such mixtures as prunes or apples with rice, tapioca, or the 
other cereals. 

No cakes, pies, and similar pastries, nor fresh bread should be 
allowed, nor may fried foods of any description. These are 
especially mentioned since mothers and nurses are frequently 
tempted to give them. The other interdicted foods and drinks 
are all those not included in the list given above. 



FEEDING 95 

Feeding in Acute Sickness 

When a child is struggling with an acute disease, his food must 
be as simple and as easily digested as possible and at the same 
time reduced in quantify. A child at breast should be allowed to 
nurse no longer than two-thirds or one-half of his regular time, and 
one who is past that period should have his food sufficiently atten- 
uated to preclude the possibility of added digestive derangements. 
All of these little patients require a liberal quantity of pure water, 
the infant being satisfied with teaspoonfuls while the half -grown 
child demands ounces. In some diseases, such as pneumonia, the 
amount of food must be reduced in order that the suddenly en- 
larged digestive tract may not take up too much of the already 
curtailed visceral space. In all these cases the object in view is 
merely to sustain the patient's vitality until convalescence sets 
in, rather than to attempt to fulfil all the needs of the healthy 
organism. 

In many cases milk, which is commonly the basis of food in 
sickness, is not easily digested, especially the proteids. To over- 
come this difficulty it may be predigested or peptonized. The 
process consists of mixing with each pint of milk a peptonizing 
powder composed of one gramme (gr. xv) of bicarbonate of soda 
and three-tenths of a gramme (gr. v) of pancreatic extract. The 
jar containing the milk is then placed in water of the approximate 
temperature of 43° C. (110° F.) and occasionally agitated. The 
object of the procedure is to convert the proteids into peptones. 
The thoroughness and completeness with which this is done de- 
pends upon the length of time during which the digestion is allowed 
to continue. As short a time as five or six minutes has an appre- 
ciable effect upon assimilability of the food, while the limit of the 
conversion takes place in two hours. The use of the peptonized 
milk should not be continued for too long a time under penalty of 
reducing the tonicity of the gastro-intestinal tube. In some cases 
one may use kumyss instead of the plain or peptonized milk. 
This preparation was originally made by the Tartars from mare's 
milk which had undergone fermentation through the agency of 
kefir grains. At the present time cow's milk is used as a body. 
The particular value of kumyss comes from the breaking up of the 
casein, with the resulting formation of alcohol, lactic acid, carbon 
dioxide, and some other less thoroughly identified products. An- 



96 THE MEDICAL DISEASES OF CHILDHOOD 

other similar preparation is matzoon. The manufacture of this 
article was brought from Asia Minor where, from the beginning, 
the basis of the product was cow's milk which had gone through a 
course of fermentation. Both proteids and milk-sugar are thereby 
changed and split up into alcohol, lactic acid, and carbon dioxide, 
as in kumyss, but the amounts formed are not the same in both. 
For very young children they may be diluted. 

Some other articles of diet for acutely sick children are beef 
juice and beef extract. The first may be made by lightly broil- 
ing a piece of beef (top round, for example) and then expressing 
the juice with a wooden lemon squeezer. The second is prepared 
by cutting the meat into small cubes after having removed all the 
fat. The pieces are then placed in a Mason jar, which is to be 
tightly closed, and placed on the fire in a kettle of water. The 
water is allowed to simmer until the red color of the meat turns 
into a brownish gray. The juice is then expressed as in making 
beef juice. The beef extract has more nourishment and is there- 
fore more of a true food than the juice which may be classified 
under the heading of stimulants. The meat broths, made from 
beef, mutton, or veal, are likewise valuable. They are the result 
of steady cooking for two or more hours. Before being served 
they should be freed from their fat and seasoned with salt. Fari- 
naceous food in the form of barley, rice, and oatmeal water may 
be of decided use for children over the age of infancy. In pre- 
paring them the grain must be allowed to stand in water until 
it is cleansed and softened. It must next be boiled from two 
and a half to three hours and then strained. Older children 
when convalescent may enjoy junket, curds and whey, wine- whey 
and custards. 

Dentition 

The subject of dentition has furnished a never-ending source 
of discussion. Expert opinion has decided on a fairly uniform 
opinion about it which in almost all other cases would be suffi- 
cient to settle the matter once and for all. But this subject is 
different from others, both in the liberal exceptions which the 
profession makes to the strict application of the standard opinion 
enunciated by experts, and the tenacity with which laymen hold 
to ideas which were formerly held concerning it. Therefore a 



FEEDING 97 

real need exists for endeavoring to settle the question in a simple 
and final way. 

In former times the eruption of the teeth was supposed to 
bring with it a necessary train of concurrent diseases. Not only 
were attacks of bronchitis, gastritis, and otitis referred to it, but 
likewise any disability which happened to appear while the teeth 
were forcing their way through the gums. Such an setiology was 
so indiscriminate, so clearly lacking in the elemental relations of 
cause and effect, that even cursory observers became dissatisfied 
with it. A large proportion of children, by uninterruptedly going 
through the period of dentition, seemed to be an active protest 
against such a rule. And as medical knowledge increased, more 
and more of the diseases which were formerly attributed to denti- 
tion were shown positively to have quite other causes. This ex- 
perience rendered observers bolder in declaring the innocuousness 
of the dentition-process. 

In spite of all this, the subconscious belief in the dangerous 
tendencies which children have in the time of teething is very 
strong. In spite of all attempts to dissipate the old beliefs, par- 
ents notice that during the period from six months to two and 
one-half years of age children are commonly subject to all manner 
of gastro-intestinal and pulmonary disorders, of earache and ner- 
vous irritations. And until these are satisfactorily explained, 
their proper connection with dentition cannot be properly under- 
stood, nor, in consequence, will they be adequately treated. 

It is unquestionably a fact that any physiological process, as 
long as it is in no way abnormal, should complete its formation 
with practically no disturbance. Following this rule, dentition, 
in its natural evolution, gives rise to no appreciable symptoms. 
Very often the process is not absolutely normal, and often the 
variation should be classified as functional rather than organic. 
One of the penalties of civilization is the notable complexity and 
sensitiveness of nerve functions which cause so many of our disa- 
bilities. On account of such considerations, various processes 
which are purely "physiological" come to have a character that 
is strikingly allied to the pathological. Thus parturition, which, 
in a perfectly natural state is a matter of inconsiderable distur- 
bance, under the conditions of civilized life becomes burdened at 
times with the most striking possibilities of pain and sickness. 
Menstruation is another example of a similar sort ; and others 



■■■ 



98 THE MEDICAL DISEASES OF CHILDHOOD 

will suggest themselves on a fair amount of thought. In a like 
manner one should reason about teething, and at the same time 
recognize the limitations that control the possibilities of acquired 
nervous irritability. Thus, for example, we know that, in the 
presence of the comparatively slight congestion and swelling 
which attend the irruption of the teeth, the accompanying pain 
may be out of proportion to the ostensible cause. Also we know 
that the blood currents supplying the jaws and the middle ear are 
closely related. Consequently one can readily see how earache 
should at times accompany a difficult dentition which is attended 
by an unusual nervous reflex like that mentioned above. But one 
should remember that between such a state and that of a purulent 
otitis media is a far cry. 

Following out this train of thought one can easily understand 
how the impaired nervous innervation of the young child would 
render him an easier victim to disorders of any kind than before 
the irritation existed, merely because his power of resistance is 
lessened. In this way he becomes an easy victim of gastric and 
pulmonary disorders, and not because teething and disease are 
naturally bound together. Any other condition which brought 
with it similarly acute accompaniment of nervous wear and tear 
would be followed by an equal number of coughs, colds, diarrhoeas, 
and similar troubles. Therefore the relation between dentition 
and the sicknesses that are supposed to accompany it is at best 
an indirect one. Also, one may, with equal assurance, say that 
the cases of convulsions of which one so commonly hears as the 
result of teething are in almost all cases due to intestinal fermen- 
tation or other well-known causes. The cases of convulsions due 
to direct irritation from the gums are so rare that the ordinary 
practitioner is not apt to see more than one or two of them in a 
life-time. 

It follows from all this that the habit of lancing the gums to 
facilitate the irruption of a tooth is in almost all cases useless. 
In fact, one would be quite conservative in stating that lancing a 
gum never helps a tooth to appear. One should remember that 
the teeth are not prepared to spring forth whenever the superim- 
posed gum is divided ; moreover, when the gum is cut the aper- 
ture does not become larger, as it would if it were made in an 
elastic membrane stretched over a pushing object. On the con- 
trary, it remains unchanged, the tooth is not at all hurried in its 



FEEDING 99 

progress, and all that one has accomplished by the operation is a 
partial relief of the local congestion. In extremely rare cases 
this may be of some value ; but over against it one should set 
the tenderness and soreness which arise from the cutting of the 
gum. A child who has been irritated and worn out by the pain, 
the sleeplessness, and the nervous stress which follow difficult 
dentition is in no condition to withstand the added discomfort and 
possible infection that may be associated with this operation. 

In this connection it is worth while to recall the manner in 
which the teeth develop. Long before the seventh month of age, 
the average time for the appearance of the first tooth, they are 
working their way into their final place and position. 1 " Even as 
soon as the seventh month of foetal life, the alveolar processes 
contain a series of crypts, corresponding to the twenty milk teeth, 
for which they later on furnish lodgment. Soon the crowns of 
all these teeth are partially calcified. In addition to the milk 
teeth, the jaws contain the dental sacs of the permanent incisors, 
canines, bicuspids, and first molars. The first upper molars lie 
behind the second temporary molars, but are not lodged in alveoli 
or sockets ; indeed, at this period of life, the crypts for the second 
temporary molars have no posterior walls, and so resemble mere 
depressions rather than clearly cut pockets. In the lower jaw 
the crypts for the second temporary molars extend as far back as 
the basis of the coronoid processes, while the first permanent 
molars lie underneath these processes. . . . Thus one sees that the 
development of the permanent teeth, except the second and third 
molars, begins early in foetal life and continues for some years. 
The germs of the second molars appear a little before the end of 
the first year, but those of the third molars as late as the fifth 
year. . . . An interesting fact is that there is not room in the 
young jaws for the teeth before their irruption to lie in a series ; 
for this reason the central incisors overlap the lateral ones, and the 
canines are pushed up above the other teeth." 

The appearance of the teeth in time and order follows no 
invariable rule. At times one sees a child with one or more teeth 
at birth ; again, in other children, especially the poorly nourished 
and rachitic ones, they may not appear until some time in the 
second year. A plan giving the average in time and order of 
appearance is appended, although its importance is not marked. 

1 "The Development of the Child," by Nathan Oppenheim, Macmillan Co. 



H^HBfl 



100 



THE MEDICAL DISEASES OF CHILDHOOD 



Temporary or Milk Teeth 



(1) Lower central incisors 

(2) Upper central incisors 

(3) Upper lateral incisors 

(4) Lower lateral incisors 

(5) Molars (first) . 

(6) Canines 

(7) Second molars . 



7th month 
9-16 months 
10-16 months 
13-17 months 
16-21 months 
16-25 months 
24-30 months 
Total 20 




am 




LHQ 




UPPER JAW LOWER JAW 

Pig. 1 — Diagram of temporary or " milk " teeth in the order of eruption. 



Permanent Teeth 



(1) First molars 

(2) Middle incisors . 

(3) Lateral incisors . 

(4) First bicuspids . 

(5) Second bicuspids 

(6) Canines 

(7) Second molars . 

(8) Third molars . 



6 years 

7 years 

8 years 

9 years 
10 years 

11-13 years 

12-14 years 

17-25 years 

Total 32 





UPPER JAW LOWER JAW 

Fig. 2 — Diagram of permanent teeth in the order of eruption. 



CHAPTER VII 
DISEASES OF THE MOUTH AND (ESOPHAGUS 

Pathological Conditions of the Lips 

In children the lips are rarely the seat of a primary inflam- 
mation. Injuries are responsible for a large proportion of the 
secondary inflammatory disorders ; here infection may take place 
and result in an acute or subacute cheilitis of varying depth. 
The treatment of this condition is surgical. Not often one sees a 
furuncle ; but when it occurs and is not properly treated, it may 
give rise to a deep-seated inflammation. It is merely necessaiy 
to mention the fact, for there is no peculiarity in it that appertains 
to childhood. In like fashion one should mention the occurrence 
of herpes of the lip. Such an eruption may be seen in poorly 
nourished children, especially those who are suffering from dis- 
orders of the gastro-intestinal track, or from the acute infectious 
diseases. Still more frequently an eczema of the lips, especially 
the upper one, results after a rhinitis. A chronic inflammation 
of the nasal mucous membrane, such as that which accompanies 
the presence of adenoid fungations, is very apt by the action of 
its acrid discharge to cause an irritation of the skin and mucous 
membrane of the lip. Cure follows removal of the rhinitis and 
the application of protective and emollient ointments. Before 
healing has resulted, the abrasions and cracks in the surface act 
as a fertile culture ground for erysipelas and lymphangitis. The 
mere mention of these possibilities is enough to show the impor- 
tance of guarding against them. 

In rare cases one sees in connection with macroglossia an 
accompanying macrocheilia. 

Hare-Lip and Cleft Palate 

Hare-lip and cleft palate are congenital deformities, due to 
deficient development, which on account of their frequency of 

101 



102 THE MEDICAL DISEASES OF CHILDHOOD 

occurrence and the marked influence that they exert on a child's 
health, logically belong in the list of active diseases. The deform- 
ity occurs in various degrees, the least of which is a slightly bifid 
uvula, while the greatest is seen in the complete cleft palate and 
double hare-lip. The bifid uvula has no more than an academic 
interest ; but the others possess a decided practical importance. 
The method by which the upper lip develops and closes in front 
of the mandibular fissure, and the palate by the inward growth 
and fusing of the palatine processes, is a matter of embryology, 
and therefore calls for no extended description in this place. 
Moreover, the radical treatment, which is purely surgical, must 
be ascertained from works upon surgery, and should be under- 
taken only by a skilled surgeon. But it is distinctly pertinent to 
mention some of the important facts concerning the course of the 
troubles which arise from the deformities. 

The effects of these disorders are in proportion to the amount 
of functional disability which they impose upon the acts of feeding 
and swallowing. A partial or one-sided hare-lip prevents the 
efficient closing of the buccal cavity and the making of a vacuum, 
and therefore renders sucking difficult. If the hare-lip is double, 
the inefficiency is much increased. If cleft palate exists, the nose 
and mouth are practically turned into one cavity, food regurgitates 
through the nostrils, suction is correspondingly lessened, and the 
child literally starves if he has no other method of obtaining 
nourishment. For this reason, it may be necessary to feed him 
with a teaspoon or, if he is very weak, by means of a large medi- 
cine dropper. Such children are apt to be congenitally deficient 
in general vitality, and therefore the problem of rearing them 
becomes a difficult and complicated one. The question of im- 
paired phonation comes up later on, when the child should begin 
to talk ; but it is suggested by the thin, nasal cry, which will be 
noticed at birth, if the cleft in the palate is at all considerable. 

It is not hard to deduce the other common sequels to hare-lip 
and cleft palate : the defective development is often a local mani- 
festation of a general condition, and outside of it we are apt to 
find other deficiencies present. On account of the imperfect 
closure of the mouth and nose, the mucous membrane is exposed 
and readily falls into a condition of subacute or chronic irritation 
and inflammation. The air which passes through the nose is not 
sufficiently warmed and filtered, and this may occasion disorders 



mmmmmam—mmaam 



DISEASES OF THE MOUTH AND (ESOPHAGUS 103 

of the respiratory track. Disorders of the stomach and intestines 
may follow insufficient feeding and the swallowing of unclean 
matters which may accumulate in the open mouth. 

The time of operation for hare-lip depends upon the child's 
vitality. If there is sufficient strength to withstand the slight 
loss of blood and the effects of the ansesthetic, the hare-lip may be 
corrected within the first month or two. No more definite rule than 
this can be laid down, for there may be the greatest variation in 
strength as well as the amount of deformity between various cases. 
If the operation has been successfully completed, a gradual change 
for the better may be expected in the shape of the superior max- 
illa, and therefore in the cleft palate. The operation for the lat- 
ter deformity may, therefore, be postponed until some time in the 
second or third year. 

A certain amount of prophylactic treatment is possible. These 
disorders seem to occur in families, and the hereditary element 
should not be attributed to the direct laws of descent which tend 
to hand on a definite characteristic to succeeding generations, but 
rather to the weakened tissues of the parents. The offspring of 
asthenic organisms are, naturally enough, apt to be defective. 
" Maternal impressions," as a factor in the setiology, have very 
little importance. Therefore, if parents are unhealthy or if there 
has been a case of hare-lip and cleft palate in the family, they 
should receive the tonic treatment whose aim is to supply the 
strength and vitality which they lack. The father as well as the 
mother needs such attention; and some observers believe that 
weakness in the former is a more telling factor than in the latter. 
The indicated treatment is the use of the compound syrup of 
hypophosphites plus the careful regulation of the diet, exercise, 
and general mode of life. 

Gaxgrexe of the Cheek 

(Cancer Aqnaticus, Cancrum Oris. Noma. Stomatitis Gangrenosa) 

Atrophic and degenerative conditions in young children are 
common. But as a rule they are easily controlled. When suffi- 
cient vitality is restored, the patient, to all appearances, enjoys as 
good health as ever. In some cases, however, the process becomes 
so marked as to result in a profound destruction of tissue. This 
may occur in almost any part of the body. The location is often 



104 THE MEDICAL DISEASES OF CHILDHOOD 

decided by some injury, possibly a small one. No matter how 
small it is, it is large enough to admit micro-organisms which 
thereafter are able to flourish in proportion to the patient's de- 
bility. As the disease occurs in children under nine years old, 
the resistance which they offer is not very great. 

Causes. — Since the mouth is very liable to injury on account 
of the habit of young children of putting all sorts of things into 
it, it is oftener than any other part of the body the seat of gan- 
grene. The disease rarely happens in robust children ; on the 
contrary, almost invariably one finds a weak and poorly nourished 
patient, usually with a history of a recent sickness such as measles, 
pertussis, or other acute infectious fevers, whose general atony in- 
vites disaster. Sometimes one finds a previous stomatitis, although 
this is not necessarily of pathological importance. Some observers 
believe that the abuse of mercury is sufficient to start in motion a 
stomatitis of such severity that gangrene must certainly follow. 
In the diseased area various pathogenic micro-organisms may be 
found. 

Lesions. — The pathological changes begin on the mucous 
membrane of the cheek, usually near the teeth and not far from 
the corner of the mouth. The mucous membrane becomes de- 
vitalized, dark, and hard. The tissue then begins to break down, 
and the gangrenous process is fairly started. It may spread in 
all directions and attack muscular and osseous tissue as well as 
the more delicate mucous membrane. Soon a perforation of the 
cheek is formed which spreads at first laterally and then in all 
directions. 

Symptoms. — Almost always the patient has been suffering 
from a stomatitis and general debility. One's attention is drawn 
to the bad odor of the child's mouth, and a small spot of severe 
inflammation in the cheek. Given these conditions, one is almost 
sure of the diagnosis. About the inflamed spot the tissues be- 
come swollen and heavy, the natural hue changes to an unnatu- 
rally dark one, which becomes more pronounced as the process 
develops. These stages become exaggerated in proportion to 
the child's atony, until the cheek begins to break down. The 
progress of the disease is now rapid, and is accompanied by 
an offensive discharge, falling out of the teeth, and an involve- 
ment of the deeper bony structures. Although the blood-vessels 
are destroyed, nevertheless one rarely sees extensive hsemor- 



DISEASES OF THE MOUTH AND (ESOPHAGUS 105 

rhages, doubtless because they are filled with thrombi and plugs 
of coagulation material. The temperature fluctuates, being in- 
fluenced by the marked prostration and sepsis which accompany 
the disease. These factors at the same time are doubtless respon- 
sible for the frequent involvement of the lungs, stomach, intestines, 
and kidneys which are so apt to occur in this disease. Curiously 
enough, although there is such an extensive destruction of tissue, 
nevertheless there is but little pain, doubtless on account of the 
local paralysis of sensory nerves due to profound inanition. 

It is not easy to confound this disease with another, even an 
ulcerative process. For the symptoms are so marked and the 
progress toward a fatal termination so impressive, that even an 
inexperienced attendant very soon recognizes the nature of the 
disease. Occasionally one sees or hears of a case where the pro- 
cess limited itself to a small area which sloughed away and 
allowed spontaneous recovery. Such cases are, however, very 
exceptional, since the child's lack of vitality is generally suffi- 
cient to bring death. This may happen in a few days or a few 
weeks. 

Treatment. — Outside of the cleanliness and general hygiene 
of the mouth which may prevent the gangrene, there is no pal- 
liative treatment. As soon as a diagnosis is made, the offending 
area must be cut out with a liberal incision and the seemingly 
healthy periphery burned with the Paquelin or galvano-cautery. 
In incipient cases some practitioners advise the application to the 
mucous membrane of a saturated solution of chloride of zinc on 
cotton for five or ten minutes. The less delay in adopting these 
measures, the less will be the ultimate destruction of tissue and 
resulting deformity. Every effort should be made by means of 
hygiene, diet, stimulants, and tonics to increase the patient's vital- 
ity. Thus, combinations of iron and strychnine may be of some 
use, and alcohol in the form of good wines, whiskey or brandy is 
well tolerated. Food must be given as liberally as the digestive 
faculty permits, and although the separate amounts may be small, 
the collective quantities must be large. Especial pains must be 
taken to keep the mouth scrupulously clean. 

Prognosis. — The prognosis is bad, and a large majority of the 
cases go on uninterruptedly to a fatal termination. 



106 THE MEDICAL DISEASES OF CHILDHOOD 



Simple Erosions of the Mouth 

Young children are apt, as a result of injuries from rubber 
nipples, their finger nails, or hard substances which they put into 
their mouths, to wear away and destroy the mucous membrane of 
some portion of the mouth. The habit of tongue-sucking may 
cause these erosions to appear in the hard palate. In the ordi- 
nary cases the injury is small and superficial, and it becomes seri- 
ous only when neglect permits the cause to continue. When they 
appear in new-born children on the hard palate about the middle 
line and near the velum, or upon the soft palate, they are called 
Bednar's aphthae. They are very superficial ulcers, with a gray- 
ish or yellow-grayish base. 

Usually these children are poorly nourished. Proper care of 
the patient's general condition, plus a removal of the cause and 
cleanliness of the mouth, will bring about a healing of the injured 
mucous membrane. A useful mouth wash for this condition is a 
combination of saturated solution of boric acid and peroxide of 
hydrogen in equal parts. 

Ulcerative Gingivitis 

Causes. — This disease, commonly known as ulcerative stoma- 
titis, is really a disorder of the gums. The process begins on the 
gums, about one or more teeth, and the pathological changes are 
for the most part confined to this place. It occurs in poorly 
nourished and poorly cared for children of from three to nine 
years of age. Given poor local and general conditions, any one 
of a number of causes can set the characteristic inflammation in 
motion. Residence in hospitals and asylums, the presence of 
pathogenic bacteria, the administration of mercury, arsenic, lead, 
and phosphorus are some of them. In infantile scorbutus it is 
often seen as well as in weak children who suffer from carious 
teeth. At times it occurs in localized epidemics, most of all where 
hygienic conditions are unfavorable. 

Lesions. — This disorder is first seen on the outside mucous 
margin of the lower jaw, usually on the lateral aspect. Thence it 
may spread in all directions, but only in severe or uncared-for 
cases does it extend to the upper gums and the rest of the mouth. 
The gums become swollen, tender, and easily abraded. Then a 
grayish membrane with a tinge of yellow in it begins to appear. 



DISEASES OF THE MOUTH AKD (ESOPHAGUS 107 

This is composed of niucus, epithelial debris, and bacteria. As 
this membrane forms, the tissue of the gums is destroyed, espe- 
cially about the teeth. These may fall out, and about their cavities 
as well as in the ulcers which appear in the continuity of the gum, 
a necrobiotic process may start which results in a localized de- 
struction of the underlying periosteum. 

Symptoms. — At the onset of the disease one can plainly 
notice an offensive odor from the child's mouth. Thus one's 
attention is immediately drawn to the seat of the disorder. It is 
easy to recognize the large indented tongue and the swollen, 
coated gums in the mild cases, and the bleeding foci, the ulcers, 
the loose teeth, and the osteo-necrosis of the severer ones. Man- 
ual examination will demonstrate the swollen, tender glands under 
the jaw. One is sure to find more or less constitutional, as well 
as temporary, depression and malaise, with a loss of restfulness, 
appetite, flesh, and strength. 

Treatment. — The treatment depends in the first place on the 
cause, and then upon the condition. Whatever the active cause 
may be, one must carefully and assiduously seek it out and remove 
it. Where, as in the case of infantile scurvy, it requires a defi- 
nite treatment and diet, such measures should immediately be 
begun. In addition one should use a spray or mouth wash of 
equal parts of peroxide of hydrogen and saturated solution of 
boracic acid. In case there are loose teeth or sequestra of bone, 
they should be removed, so that infecting cavities and pockets may 
be exposed and cleansed. 

Chlorate of potash is regarded as a specific remedy. A three- 
year-old child may take 0.2 gm. (3 gr.) of the drug every three 
hours. But one must watch for the prostration and cardiac weak- 
ness with which it overwhelms some susceptible children. 

Eveiy effort must be made to improve the patient's sanitary 
and hygienic surroundings, and to fortify his general condition 
by diet and tonics. 

Prognosis. — The prognosis varies with the treatment. If the 
care of the child is intelligent and unremitting, he will rapidly 
recover. If he lingers for weeks in an unsatisfactory state, the 
attendants are apt to be at fault. Complications in the way 
of bone necrosis, and various forms of stomatitis, may delay 
recovery. 



■l^MHH^HHB 



108 THE MEDICAL DISEASES OF CHILDHOOD 



Simple Acute Stomatitis 

Causes. — One of the most common complaints of children, 
especially the very young, is a catarrhal inflammation of the mouth. 
In most cases it occurs in connection with derangements of 
the gastro-intestinal track associated with the local irritation due 
to lack of cleanliness, injuries, the excessive use of mercury, chilled 
or overheated food, and the tendency in the acute eruptive fevers 
to inflammation of the mucous membranes. 

Lesions. — The mucous membrane of the mouth, or any part 
of it, is swollen and congested. There may be more or less 
degeneration of the epithelial cells, which, when sufficiently 
marked, results in death of the tissue and the consequent form- 
ation of white patches. The muciferous glands are enlarged and 
congested, and thus may secrete an unusual amount of discharge. 
On the other hand, in a few cases the congestive disturbances may 
be so obstructive that the glandular functions are temporarily 
obliterated and the mouth becomes hot and dry. Occasionally 
the obstruction may be so great that the glands become markedly 
swollen, enlarged, and cystlike. Regularly one may expect to see 
an accompanying enlargement of the associated glands. 

Symptoms. — Although the symptoms are not hard to discover, 
they are nevertheless frequently overlooked. The child's mother 
usually believes that they are due to some disorder of the stomach; 
and as they commonly cause no great constitutional disturbance, 
she may not at first seek relief. When the case is brought to the 
physician's notice, he will distinguish a hot, inflamed condition of 
the mucous membrane, which in marked cases is accompanied with 
considerable swelling. The saliva is so plainly acrid in its action 
that the skin of the lower lip and chin may be raw and inflamed. 
The tongue is coated with a white fur which gradually takes on 
a darker, dirtier hue. Here and there, piece by piece, this coating 
disappears, until finally nothing remains. The tongue may then be 
unusually red and tender, as if covered by a new and very delicate 
epithelium. Sometimes, as the coating wears off, the surface is 
seen to be studded with superficial ulcers of varying size. In a 
large proportion of cases there may be some fretfulness and con- 
stitutional disturbance; in other children the disability may be 
purely local, and in some the little patient may seem not at all 
incommoded. 



■■■■^^■i 



DISEASES OF THE MOUTH AXD (ESOPHAGUS 109 

Treatment. — The treatment consists in removing whatever 
cause one may discover, and then in exercising rigid cleanliness. 
It is always wise to act as if there were a precedent gastric or 
gastro-intestinal disorder. This will necessitate a thorough 
cleansing of the stomach and intestines, and a careful regulation 
of the food. The mouth should be frequently sprayed with 
a saturated solution of boric acid. At intervals of two or three 
hours it should be swabbed out with cotton moistened in the same 
solution. In exceptional cases the ulcers may require the applica- 
tion of a dilute solution of silver. This measure should not be 
adopted until one is sure of its absolute necessity. 

The outcome of these cases is almost always favorable, although 
the length of time consumed in treatment is variable. 

Herpetoid Stomatitis 

Causes. — This simple disorder has been the cause of much 
discussion, and at the same time full research in its phenomena 
has been lacking. At various times it has been differently desig- 
nated, having had the names follicular, aphthous, vesicular, and 
herpetic stomatitis. Our knowledge concerning it is mostly nega- 
tive, so that we are more able to say what it is not than what it 
actually is. All that one can state is that it never occurs without 
a simple acute stomatitis, that it probably has some connection 
with disorders of the stomach and their sequelie, that it is doubt- 
fully associated with bacteriological life, and that it is not con- 
tagious. 

Lesions. — The changes are neither many nor important. Out- 
side of those of simple acute stomatitis, one sees here and there a 
small vesicle lying under the epithelium. After a short time the 
epithelial layer becomes devitalized and breaks down, leaving a 
small superficial ulcer. At first the color of these vesicles is 
creamy white ; as soon as the process of devitalization begins it 
changes to a dirty hue, partly gray, partly white. The eruption 
is most often seated upon the under surface of the tongue, and in 
the furrow between the lips and gums. 

Symptoms. — In the way of symptoms, outside of the inflam- 
mation of the mucous membrane and the appearance of the 
eruption, there is a var}ung amount of constitutional disturbance, 
which, however, is rarely severe and never dangerous. This dis- 



^■■■■■^ 



110 THE MEDICAL DISEASES OF CHILDHOOD 

turt>ance is the same as that of simple stomatitis, with the possible 
exception of an added degree of intensity. The disease may last 
from a few days to two weeks. 

Treatment. — In ordinary cases no treatment beyond cleansing 
the month is called for. As a matter of routine the stomach and 
intestines should be thoroughly emptied. Where the superficial 
ulcers are slow in healing one may touch them with a weak solu- 
tion of silver nitrate. After all, washing the mouth with boracic 
acid is the main thing. 

Prognosis. — The prognosis is uniformly good. 

Mycetogenetic Stomatitis 

Causes. — This form of mouth-infection, commonly called 
thrnsh or sprue, is a further example of diseases which, on 
account of their generally harmless nature, have escaped thorough 
investigation. It is caused by the lodgement and growth on the 
mucous membrane of the mouth of a fungus lately called saccha- 
romyces albicans. In the presence of dirt it can grow on any 
mucous membrane, especially one which has a neutral or slightly 
acid reaction ; since the mouth receives greater quantities and 
more kinds of dirt than any other mucous membrane cavity, it is 
the most frequent seat of infection. 

Lesions. — Very soon after the spores of saccharomyces albicans 
find a lodging place on the mucous membrane they begin their 
natural growth, sending out great quantities of their thin white 
mycelium, which, with broken-down epithelial cells, leucocytes, 
and detritus make up the characteristic whitish fur. The spores 
find a culture-ground in the first instance in some abrasion or 
other solution of continuity ; then the growth makes its way 
between the cell elements and gradually splits up the different 
strata. For this reason of growth the development of the fungus 
is much more pronounced on squamous than on cylindrical epithe- 
lium. As this disintegration of tissue proceeds it is accompanied 
by variable amounts of congestion, swelling, and tenderness of the 
affected parts. The capillary vessels become engorged and easily 
friable, so that when the fur is swept off they may bleed from the 
slight trauma. 

Symptoms. — The symptoms are usually confined to the tongue ; 
in exceptional cases, where there is an extension to the pharynx, 



■H 



DISEASES OF THE MOUTH AND (ESOPHAGUS 111 

oesophagus, or stomach, appropriate symptoms will follow. In 
some of the rare cases of protracted extension, where deep ulcers 
result, the fungus makes its way through the walls of blood-ves- 
sels ; in consequence, metastatic deposits in any of the viscera 
may suddenly exhibit their characteristic signs. 

The common experience is, however, quite removed from such 
startling extensions. One generally sees the beginning and the 
end of the invasion limited to the mouth. At first it appears in 
small scattered masses which somewhat resemble bits of coagu- 
lated milk. These grow in size until they flow together. They 
may attack the tongue and the cheeks ; if not arrested they may 
cover the lips, the pharynx, the palate, and so extend gradually to 
the deeper parts of the alimentary track. The buccal cavity is 
sometimes seen to be dry, and the surface of the mucous membrane 
loses the soft texture of its normal condition. With the spread of 
the growth the color changes from a white to a grayish white. 
Associated with this one may distinguish the ordinary symptoms 
of a simple stomatitis. Occasionally one sees the signs of a con- 
stitutional depression, but this condition is in all likelihood due to 
causes which precede rather than follow the appearance of the 
fungus. As a rule there is little difficulty in making a diagnosis : 
for the main possibility of error lies in mistaking milk clots for 
the disease. Such clots may be easily removed by a brush or 
swab, while the growth can not. The diagnosis can be confirmed 
by a microscopical examination which will demonstrate spores, 
mycelium, and degenerated cells. 

Rigid cleanliness will remove all traces of the growth. For 
this purpose repeated washing with a saturated solution of boracic 
acid, or in severe cases with boracic acid and peroxide of hydro- 
gen, is efficient. Likewise it is advisable to clean out the gastro- 
intestinal track, and in case of general debility to fortify the 
child's health as far as possible. 

Prognosis. — The prognosis is good. The extent of the growth 
or the child's poor condition may delay a perfect recovery until 
the bad effects of poor care or constitutional disability are at least 
partially removed. 

Croupous Stomatitis 

Causes. — As the result of local irritants, the mouth may be 
covered with a membrane whose limits are defined only by the 



wm 



112 THE MEDICAL DISEASES OF CHILDHOOD 

spread of the exciting cause. Also it occurs as a complication 
of the eruptive fevers. In this case its aetiology is doubtless 
bacterial. 

Lesions. — The parts involved are covered with a false mem- 
brane which varies in thickness and in color in different cases. 
The mucous membrane is split up and partially destroyed. It is 
infiltrated with pus and a small amount of fibrin. The pus, fibrin, 
and coagulated epithelium make up the false membrane. 

Symptoms. — In addition to the formation of membrane, there 
may be considerable general disturbance, malaise, lack of appetite 
and strength, as well as disorders of the gastro-intestinal system. 
There may be fetor and a foul discharge from the mouth ; and 
commonly the buccal tissues are both tender and painful. Within 
a few days or a week the false membrane falls off, leaving a bare 
and sometimes bleeding surface. Very rarely there may be a 
noteworthy haemorrhage. 

Treatment. — The treatment consists in maintaining cleanliness 
in the mouth by means of repeated washing and spraying with 
boracic acid solutions. Any precedent abnormal conditions must 
be carefully looked after and the stomach must be maintained in 
good condition. 

Prognosis. — The prognosis is generally good. 

GONORRHEAL STOMATITIS 

This infection is in children almost entirely confined to the 
new-born whose stomal mucous membrane becomes contami- 
nated through some abrasion. The gonococcus burrows underneath 
the upper epithelium, producing an acute inflammation. This is 
followed by the appearance of creamy patches. At the same time 
the general health is not seriously compromised. 

The treatment consists in constant cleansing with a saturated 
solution of boracic acid ; in severe cases, a mixture of boracic acid 
solution with peroxide of hydrogen is efficient. 

These cases are commonly complicated with a gonorrhceal 
ophthalmia that is much severer and more serious. Syphilitic 
and diphtheritic stomatitis are treated in their respective places 
under the headings of the diseases, syphilis and diphtheria. 



DISEASES OF THE MOUTH AND (ESOPHAGUS 113 

Simple Superficial Glossitis 

The superficial epithelium of the tongue is often the seat of 
disorders which in most cases are of small importance. The 
transitory catarrhal condition, known as coated tongue, is the ac- 
companiment of most diseases. Here the epithelium becomes 
weakened and desquamates, and the resulting detritus, when 
mixed with saliva and particles of food, produces the characteris- 
tic coating. This tendency to desquamation exists in some 
children who in other respects are healthy, so that a coated 
tongue may be always present. 

Another familiar condition may be that of the strawberry tongue 
of scarlet fever, where the fungiform papillae are sufficiently swol- 
len to suggest the appearance of a strawberry ; or very rarely one 
may see a swelling and enlargement of the filiform papillae consti- 
tuting the so-called hairy tongue. 

More commonly one sees variousl}' shaped, benign patches on 
the back of the tongue which may result from lack of cleanliness, 
too much roughness in washing the mouth, or a rough nipple or 
the sharp edge of a tooth. Outside of the appearance there are 
no especial symptoms. In the cases where the confluence of the 
patches, in the centre of which the process of healing is going on, 
creates a number of irregular lines on the dorsum of the tongue, 
the name of geographical tongue has been applied. Where the 
superficial horny epithelium has entirely degenerated and fallen 
off, the whole tongue may have a strong red color. 

For all such conditions no further treatment than washing 
with boracic acid is needed. If much of the tongue is affected, 
relief may more rapidly be obtained by local applications of a 
weak (one-half per cent) solution of argentic nitrate. 

Acute Glossitis 

Occasionally a child may, by some accident, hurt or bite his 
tongue. The great number of micro-organisms in the mouth then 
renders infection easy. As a result, the tongue may become acutely 
inflamed, the parenchyma may be swollen and infiltrated with 
serum and pus, and the child will present the various symptoms 
which naturally belong to such a condition. These symptoms are 
rarely serious, for the most part being no more than inconvenient. 



wmm 



114 



THE MEDICAL DISEASES OF CHILDHOOD 



If the organ is much swollen, it may be necessary to feed the 
child by means of a tube passed through the nostril. Children 
who are old enough to follow directions can be spared discomfort 
if they are ordered to keep small pieces of ice in the mouth. In 
almost all cases, thorough and continued disinfection of the mouth 
will reduce the disorder. Exceptionally an abscess may result ; 
when it does, one is very apt to overlook it. After opening it, 
one should cleanse it very often by means of a spray or gargle 
composed of peroxide of hydrogen and a saturated solution of 
boracic acid. 

Acute Oesophagitis 

Inflammation of the (esophagus in children is rare, and hardly 
ever does it occur as a primary disorder. The rule is that an 




Fig. 3. — Croupous or Membranous Oesophagitis. X 25. 

acute catarrhal inflammation may follow an extension of a similar 
disorder in the pharynx or other near-by region, or it may be 
caused by the passage through the oesophagus of some foreign 
body, which, on account of its size or form, irritates the mucous 
membrane. Attention to diet and cleanliness of the mouth con- 
stitute the treatment. 



DISEASES OF THE MOUTH AND (ESOPHAGUS 115 

As an extension of a croupous inflammation of the pharynx or 
near-by parts and the stomach, from swallowing irritating chemi- 
cal substances and foreign bodies, and as a sequel of the acute 
fevers, a croupous oesophagitis may start up. In case of recovery 
the injured parts heal by granulation and thus give rise to the pos- 
sibility of stenosis and contractions of the oesophageal tube. These 
are serious in proportion to the extent of surface involved and the 
depth of the injury. The consequent deformities follow no spe- 
cial rule and may be of any shape. Following these deformities 
one may find dilatations which, in turn, may give an opportunity 
for the creation of a rupture of the wall. The same result may 
be obtained by an ulcer or localized abscess in the inflamed sur- 
face. In consequence, pus or a foreign body may find its way 
into some neighboring part. 

The symptoms of oesophagitis are not easily separated from 
those of the related parts. The patient suffers from pain, dyspha- 
gia, thirst, anorexia, and malaise. The pus, blood, and pieces of 
membrane which are thrown off in the progress of the disease 
may be swallowed and then vomited. And the physician should 
be careful not to ascribe such an occurrence to organic lesions of 
the stomach. 

The treatment is symptomatic. 

Retro-CEsophageal Lymph-Adenitis 

Causes. — The causes which produce an inflammation of the 
retropharyngeal lymph glands may excite a similar inflammation 
of those behind the oesophagus. The symptoms occur in the 
form of pain, restlessness, slight dysphagia, fever, and a more 
or less poorly defined tumor. The swelling may, by pressing 
upon the pneumogastric nerve, render the condition most criti- 
cal. 

This inflammation may also be tubercular, following a tuber- 
cular condition of the cervical vertebrae. In both cases the aid 
of a surgeon must be sought. 

Treatment. — The treatment may be summed up in attention 
to the symptoms, or tracheotomy. As soon as the case comes 
under observation one should employ ice and antiseptic sprays 
in the mouth and ice bags to the neck. The bowels should be 
thoroughly emptied and the diet restricted to fluids. The patient 



116 THE MEDICAL DISEASES OF CHILDHOOD 

must be confined to bed and protected against the possible irri- 
tations which may be involved in unnecessary exposure and 
movement. 

Prognosis. — The prognosis is bad, especially in the tubercular 
variety. 



CHAPTER VIII 
DISEASES OF THE STOMACH AND SMALL INTESTINE 

Acute Functional Derangement of the Stomach 

One of the most frequent ills of children is a disordered con- 
dition of the stomach, which is due to wrong feeding. Under this 
head one includes eating too much, or too rapidly, or eating un- 



\ 




Fig. 4. — Normal Stomach, x 10. 

suitable articles of food. Likewise, a sudden nervous shock, an 
impression of fear, a blow or fall, or even the irritation of denti- 
tion, or a fit of temper, may be the starting-point of an arrest of 
gastric secretions and gastric activity. At the same time, one 
should not make the mistake of confusing the more serious or long- 
continued cases, where a real gastritis may exist, with these in- 
stances of nature's attempt to rid the stomach of its undesirable 
contents. 

117 



mma^^ 



118 THE MEDICAL DISEASES OF CHILDHOOD 

Lesions. — There are no characteristic pathological changes, 
with the possible exception, in individual cases, of transitory con- 
gestion, or anaemia of the mucosa. It is only when the abnormal 
causative conditions from which a distinct gastritis results are con- 
tinued that characteristic changes occur. We are ignorant of the 
exact pathology of the nervous depression which at times accom- 
panies this condition. The chemistry of the decomposition of 
food which at times attends this disorder is likewise a matter of 
future work. 

Symptoms. — The symptoms usually begin with vomiting ; in 
older children it may be accompanied by nausea and pain. The 
temperature may be slightly or much elevated, and the pulse and 
respiration may be similarly influenced. The prostration may be 
variable ; in one case very little, in another very much. Where 
prostration exists, the picture reminds one at times of a case of 
poisoning — the possible stupor or delirium, the contracted pupils, 
the spasmodic vomiting with or without a straining diarrhoea. 
The tongue is coated, the breath may have a foul odor. 

Treatment. — As a rule, these cases recover very rapidly. By 
emptying the stomach and intestines, providing rest and quiet, and 
restricting the diet, the evil effects are quick to pass away. For 
infants, eight or ten quarter-hourly doses of calomel (0.006 gm. — 
iV §" r followed by a mild cathartic is efficient. For older chil- 
dren calomel may be used in the same manner, or the citrate of 
magnesia by the wineglassful every fifteen minutes until the bowels 
have been thoroughly flushed out. In addition, the stomach 
should be washed out once or twice daily with plain boiled water 
until the wash water runs clear. The irritability of the stomach 
may be quieted by sucking or swallowing bits of ice, by an ice-bag 
on the epigastrium, or by the counter-irritation of mustard on the 
same region. After the stomach is quiet, sponge baths or warm 
full baths have a soothing and refreshing effect. No drugs beside 
the subgallate of bismuth are required, and this may be used in 
doses of 0.3 gm. (gr. v) every hour or two ; but when convales- 
cence is well started small doses of nux vomica or strychnine, with 
or without an organic preparation of iron, are often beneficial. 

The regulation of the diet is a matter of the first impor- 
tance. At the beginning all food should be withheld. When 
the stomach has become quiet, one may begin to give very 
small quantities of albumin water, diluted milk, or beef extract. 



DISEASES OF THE STOMACH AXD SMALL INTESTINE 119 

Infants may begin by taking nourishment by the teaspoonful 
every hour or two. As the patient shows ability to retain and 
digest food, the quantity may gradually be increased. 

Every effort should be made to provide rest, good ventilation, 
proper clothing, and sufficient cleanliness. 

Prognosis. — The outlook is good, especially if sufficient care 
is taken to prevent a relapse or a rapid recurrence of new attacks. 

Acute Gastritis 

This disease, formerly spoken of as acute gastric catarrh, 
acute gastric fever, or acute gastric adenitis, is an acute inflam- 




Fig. 5. — Acute Gastritis, x 30. 

mation of the glandular parenchyma of the stomach. Outside 
of the simple form, there are three varieties of inflammation, — 
the croupous, the toxic, and the suppurative. These, on account 
of their rarity, are of less importance than the simple catarrhal 
inflammation. They will therefore be spoken of at the end of 
the section on acute gastritis. 

Causes. — The most frequent cause is improper food, improper 
in chemical composition or purity, or in being excessively heated 
or cooled ; a very common factor is too short an interval between 



■■mmb 



HHM^H 



■MM 



120 



THE MEDICAL DISEASES OF CHILDHOOD 



the meals, which consequently leads to a congestion of the glandu- 
lar elements. Likewise, diseases of the intestinal and portal sys- 
tems, or any disorder, such as diathetic and wasting diseases, which 
destroys the equilibrium of the economy, may bring about a simi- 
lar result, especially in hot weather. A factor, at present unesti- 
mated, is the irritation which may be produced by bacteria and 
their toxines as well as by the putrefaction and decomposition of 
contaminated foods. The chemistry of the subject is so vast that 
the limits of it no man can now know. 




Fig. 6. —Acute Catarrhal Gastritis. X 50. 

Lesions. — The gastric surface is a deeper red than usual, 
although the color is irregularly scattered. The mucosa is 
swollen, the capillaries injected, the gastric secretions may be 
increased, decreased, or altered in composition. The epithelial 
cells are thick, cloudy, and at times eroded here and there. The 
glands may be swollen, the mucosa and even the submucosa infil- 
trated with white cells. In very severe cases the parenchyma 
may have small collections of pus enmeshed in its substance. 
There is an abnormal amount of mucus present which gravitates 
to the pyloric portion of the stomach. 

Symptoms. — The onset is usually sudden, accompanied by 



DISEASES OF THE STOMACH AND SMALL INTESTINE 121 

varying amounts of pain and fever. The limits between which 
the fever may run are A^ery wide ; in all likelihood the high tem- 
peratures, such as 40.5° and 41° C. (105° and 106° F.), are 
associated with the absorption of toxines or the products of 
decomposition rather than a mere catarrhal irritation of the 
mucosa. The child may suffer much pain, so that the legs may 
be drawn up and the muscles set. Later on the exhaustion may 
be so great that the child is prostrated. From the beginning 
vomiting may be violent and very frequent. The vomitus is 
sour, usually pale in color, sometimes mixed with bile, rarely 
streaked with blood. Inspection will occasionally show a slight 
puffiness of the epigastrium, or on palpation the area may seem 
hard and tumified. There is naturally some tenderness which, 
after the lapse of a few hours, may extend to the abdomen. The 
respiration may be hurried and shallow, and the pulse rapid and 
weak. In the beginning there may be constipation followed 
within a short time by diarrhoea, or diarrhoea alone may be pres- 
ent. The urine is high colored, high in specific gravity, and with 
a strong odor. In severe cases, or in very weak children, it may 
contain albumin and a large amount of urates. 

Complications are commonly seen, often in the way of exten- 
sions of the inflammation to other parts of the intestinal track, and 
frequently, especially in very young children, one sees lesions of 
the skin, such as erythematous eruptions. 

Treatment. — The first step is the withdrawal of all food, until 
the gastro-intestinal track has been emptied and the stomach has 
become quiet. In infants one should wash out the stomach as 
soon as possible and then give small doses of calomel (0.006 gm. — 
iV £ r everv quarter-hour until thorough catharsis has been ob- 
tained or until ten doses have been given. It is considered good 
practice to follow the calomel with a saline cathartic. After this 
the lavage may be repeated twice a day until the stomach is in a 
fairly good condition. The pyrexia may be agreeably and safely 
controlled by warm baths for infants and graduated baths for 
older children. When vomiting has fairly ceased one may begin 
to give food, in the form of albumin water or beef extract, by the 
teaspoonful. As the child shows ability to retain and digest this, 
diluted milk may be substituted for it. The return to the ordi- 
nary quantity and composition of milk must be gradual and gov- 
erned by judgment. 



^■■■^ 



122 



THE MEDICAL DISEASES OF CHILDHOOD 



In older children, lavage is not so easily practised, and the 
procedure of treatment may therefore be somewhat modified. 
The administration of calomel should be begun as soon as possible, 
and to make this the more possible the application of an ice-bag 
or a counter-irritant to the epigastrium, with the sucking of ice, 
is of use. Then, when practicable, the stomach should be washed 
out. The diet should be managed in the same careful and con- 
servative manner as with infants ; in fact, the more carefully one 
feels one's return toward an ordinary general diet, the less need 




> 



Fig. 7. — Croupous or Membranous Gastritis. X 32. 

will there be for medicines. In those cases where medicine is 
required, the subgallate of bismuth in hourly doses of 0.3 gm. 
(gr. v) will be as unobjectionable as anything. Rarely an 
alkali before or an acid after meals may be indicated. When 
convalescence is once established, one may stimulate both secre- 
tion and excretion by small doses of nux vomica. 

Croupous gastritis is so rare as to be a curiosity ; moreover, 
one is practically not able to diagnosticate it during life unless 
a piece of membrane should be vomited. Generally it follows a 
croupous inflammation of the pharynx, oesophagus, or intestines. 
In some unusual cases it has followed attacks of the exanthemata. 



DISEASES OF THE STOMACH AND SMALL INTESTINE 123 

The symptoms of the original disease cover those of the gastritis, 
so that we know very little about it except as we see it in autop- 
sies. Usually the membrane is located in scattered areas which 
may coalesce. The membrane may have a dirty white or a 
greenish-gray hue, and may be of varying thickness. It is com- 
posed of mucus, fibrin, blood, pus, and epithelial cells, epithelial 
debris, and bacteria. The inflammatory process extends through 
the mucosa and submucosa. 

Toxic gastritis results from the local action of irritant poisons, 
such as caustic acids and alkalis, salts of mercury, carbolic acid, 
phosphorus, arsenic, or antimony. There seems to be no limit to 
the remarkable devices which children are able to contrive by 
which they may poison themselves. In this way a toxic gastritis 
may be started by a great number of agents, all the way from 
matches to green candy and painted toys. 

Lesions. — The lesions vary in severity according to the con- 
centration of the poison, its amount, and the length of time which 
it remains in the stomach ; usually the} r are most marked at the 
fundus. The effects produced are some of the various degrees of 
destruction of tissue. They may vary from intense congestive 
changes to sloughs of the superficial tissues and even to an amor- 
phic, soft, pulp-like condition that easily permits of perforation. 
After the less serious injuries, contractions and scars may form 
which materially alter the shape, relation, and functional activity 
of the organ. 

The severe degeneration of tissue caused by a toxic gastritis 
must be distinguished from gastromalacia or softening of a part of 
the stomach wall, which has often been seen some hours after death. 
It is supposed to be caused by a digestion of the part where the 
gastric secretions gravitate. For this reason almost always the 
posterior wall is affected. The tissue is soft, faded in color, and 
of a disagreeable odor. 

Treatment. — The treatment of toxic gastritis must often be 
decided by the conditions of individual cases. In ordinary cases 
the stomach should be thoroughly washed out and the proper anti- 
dote administered. One must keep in mind the possibility of 
producing a perforation in the injured tissue by means of the 
stomach tube. Acid poisons should be neutralized by the admin- 
istration of dilute alkalis, and alkaline poisons by dilute acids. 
If the child begins to recover, the diet should be most carefully 



warn 



124 THE MEDICAL DISEASES OF CHILDHOOD 

regulated so that, until the ability to digest food is assured, no 
harsher nourishment than albumin water or a weak modified milk 
should be given. It is often advisable to keep the stomach clear 
by daily lavage until convalescence is well advanced. 

Suppurative gastritis is characterized by infiltrations of pus in 
the connective tissue of the stomach. It occurs in conditions of 
marked physical debility, marasmus, and after severe attacks of the 
acute infectious diseases. The pus-areas are microscopic, although 
some observers have mentioned cases where they developed suffi- 
ciently to be seen by the naked eye. The disease is recognized on 
autopsy. There is no special treatment for it. 

Chronic Gastritis 

Causes. — This is a prolonged inflammation of the gastric 
mucosa attended in severe cases by more or less permanent 
changes in the parenchyma. In its setiology an acute gastritis 
which is allowed to continue or frequently to recrudesce holds an 
important place. Other responsible factors are diseases of wast- 
ing and malnutrition, atonic conditions following the acute infec- 
tious fevers, disorders of other parts of the intestinal track, and 
diseases of the heart and lungs. 

Lesions. — On the whole, the changes are the logical outcome 
of those in the acute variety. The characteristic structure of the 
parenchyma is gradually altered. The tubules may become en- 
larged and obliterated, the cells cloudy, choked, and finally de- 
stroyed. The mucosa is seen to be roughened, and in protracted 
cases this characteristic is contributed to the submucosa. In some 
severe and long-continued cases among older children, these struc- 
tures are encroached upon by a deposition of plain connective tis- 
sue. There is an infiltration of small cells which in rare cases 
penetrates as far as the submucosa. 

Commonly there is a condition of gastric dilatation. Although 
this is seen often enough in older children, nevertheless, I believe 
it is still more frequently seen in the younger patients whose tissues 
have less power to resist the causes of gastric dilatation. In an 
undilated organ, the chronic process is severest near the pyloric 
orifice ; where dilatation exists, the whole stomach is more apt to 
be involved. In such cases there is a greater likelihood of paren- 
chymatous degeneration which is beyond repair. In the subjects 



DISEASES OF THE STOMACH AXD SMALL INTESTINE 125 

of extreme wasting an infiltration of fat globules may take place, 
Avhich likewise is final. 

On section the interior is seen to be coated with a thick, sticky 
mucus which naturally collects in largest quantity at the pylorus. 
The color of the mucous membrane in the more recent cases may 
be a dull, heavy red ; in those of long duration the hue fades to 
a dull, poorly defined gray. These colors are not necessarily uni- 
form, so that in one subject we may see many shades that vary 
from dark to almost white. 




Fig. 8. — Chronic Gastritis. X 30. 

Symptoms. — Generally it is easy to demonstrate by light per- 
cussion and succussion the tendency to dilatation. The abdomen 
may be hard to the touch, and pressure over the epigastrium as 
well as over the sigmoid flexure will often show the presence of 
tenderness. The child is apt to look flabb} r and white or ema- 
ciated. The eyes are dull, the tongue is coated, and the general 
condition is poor. On account of this atonic state, the mucous 
membrane of the throat may become congested and relaxed so 
that an obstinate pharyngeal cough may result. There may be 
frontal headache in children who are old enough to express their 
sensations in words. The appetite is capricious or deficient, and 



■■■l^MHHMMHHMH^ 



126 THE MEDICAL DISEASES OF CHILDHOOD 

at varying times after eating vomiting is apt to ensue. Intestinal 
action is irregular, so that there are periods of constipation, varied 
by attacks of diarrhoea. The patient's sleep is restless, fitful, 
and disturbed. 

Some of the main symptoms arise from the imperfect digestion 
of food. Much of this material remains in the stomach for 
hours ; proteids are only partly changed and some of the albu- 
menoses thus formed are poisonous. Evidence of imperfect diges- 
tion, especially of casein, is furnished by the presence of unchanged 
or partly changed masses of food in the stool. Also, the fats, 
mucus, and albumins ferment and decompose, with the resulting 
formation of fatty acids, gases, and a multitude of by-products 
whose chemistry is hard to follow. Absorption necessarily brings 
various degrees of low toxic conditions which not merely affect 
the body but also cause strange and remote subjective mental 
impressions. This subject of intoxication is worthy of the most 
serious attention ; for not only may it give rise to a multitude of 
mental symptoms, but also the possibility of permanent physical 
as well as psychical effects is always present. Certainly the influ- 
ence upon development has an imminent potentiality of serious 
results. 

Treatment. — The cure of these cases is simple in principle, 
although individual cases may call for the exercise of much judg- 
ment and tact. The main indications look to the rigid regula- 
tion of diet, the cleanliness of the gastro-intestinal track, and the 
support of the patient's vitality. In infants the cutting off of all 
food for a few hours, followed by the administration of small 
quantities of albumin water, weak modified milk, or beef extract 
for a few days is highly desirable. Gradually then, as the condi- 
tion of the stomach permits, the amount may be increased. In 
older children food may at first be confined to clear meat soups, 
milk, soft-boiled eggs, and scraped beef in small quantities. These 
may be so varied that, with the addition of dry toast as the treat- 
ment of the case progresses, no less easily digestible articles of 
food will be needed for some time. 

Cleanliness of the gastro-intestinal track may be promoted by 
washing the stomach out once or twice a day with plain boiled 
water. For this operation one needs a soft rubber catheter (18 to 
25 French) ; this is joined by a glass tube to one end of a rubber 
pipe about 0.5 m. (about 20 inches) in length, while into the other 



DISEASES OF THE STOMACH AND SMALL INTESTINE 127 

end a glass funnel is inserted. The procedure of passing the cathe- 
ter is very simple. The child's arms are confined to his sides by 
pinning a towel about them ; he is seated on an attendant's lap and 
his head is held by attendant's right hand. The operator's left 
forefinger is laid along the patient's tongue to act as a director, 
and then with a quick movement of the right hand the catheter is 
passed through the oesophageal opening. When the tube is in the 
stomach, the funnel is raised high in order to facilitate the escape 
of gas ; this is followed by the introduction of water, which, when 
the stomach is nearly full, is siphoned out. The operation may 
be repeated till the wash water runs clear. As it may be neces- 
sary to continue this treatment for weeks, the mother or nurse 
may be instructed in its details. 

The medicinal treatment has of late years been growing pro- 
gressively less important. The drug which will give the most 
help is nux vomica or its alkaloid, strychnine. This, by promot- 
ing peristalsis and muscular tone, may be of real service. It may 
be combined, in cases of hyperacidity, with an alkali, or where 
anacidity exists with dilute hydrochloric acid. When there is 
need for the acid, it must, to be of service, be given in large doses 
(five drops four times a day, for a child of one year). Outside of 
these drugs, one may, when convalesence is established, use small 
doses of an organic preparation of iron as a tonic. All through 
the sickness, the utmost care must be given to hygiene and con- 
trol of the patient's general mode of life. Rest, exercise, bathing, 
and clothing must be carefully reviewed and regulated. 

Differential Diagnosis. — In most cases the nature of the disor- 
der is fairly clear. The history of successive acute attacks, which 
finally merge into a chronic process, or of a chronic disposition 
from the beginning, is fairly characteristic. One of the best 
methods of differentiation is by means of a test meal, which is to 
consist of milk in infants, of bread and milk in somewhat older 
children, and of milk, bread, and meat in children of eight or more 
years. After the meal has been in the stomach for an hour, it 
should be siphoned out with the stomach tube and analyzed by 
the well-known methods which are given at length in special 
works. The main objects of information are increased secretion 
of hydrochloric acid, decreased secretion of the hydrochloric acid, 
and the quantity of mucus. At the same time one may obtain 
additional information concerning putrefaction and decomposition 



^■M 



128 THE MEDICAL DISEASES OF CHILDHOOD 

of food, the formation of gases, and the presence in the stomach of 
injurious by-products. 

In some cases the child's condition is so much depressed that 
the possibility of tuberculosis or other wasting diseases must be 
considered. But the absence of characteristic temperature and 
localized manifestations will bar the first, while the peculiar signs 
of rickets, scurvy, and similar disorders of nutrition will likewise 
be wanting. The process of exclusion is surely, although gradu- 
ally, completed by extended observation. 

Prognosis. — The outlook under favorable conditions is good. 
An ignorant, stupid parent, who does not know how to control 
his child, is more of an obstacle in the way of the patient's recov- 
ery than the disease itself. 

Dilatation of the Stomach 

Causes. — Various degrees of gastric dilatation are commonly 
seen, especially in infants. In such young children any attack of 
functional derangement or gastritis may bring about a temporary 
dilatation of the weak muscular walls. It is not often, however, 
that such a condition takes on a permanent phase. But repeated 
attacks of acute gastritis or a chronic gastritis are very apt to 
bring with them a dilatation which may have a marked persistence. 
This is in part due to the piling up of food in the stomach and 
the production of gases of decomposition which occurs when peri- 
stalsis is deficient. In this way any atonic condition could bring 
about a similar result. For this reason we are very apt to see this 
disorder in marasmus, in rachitis, in the wasting diseases. In fact, 
all conditions, such as stenosis of the pylorus or partial obstruc- 
tion of the intestine, which are able to dam back the flow of food, 
must necessarily cause a gastric dilatation. 

In some rare cases partial or sacculated dilatations may follow 
the swallowing of coins, buttons, pieces of wood and similar bodies 
which are too large to pass through the pylorus. 

Symptoms. — Very rarely does dilatation occur without a con- 
comitant chronic inflammation of the mucous membrane. The 
symptoms of the two disorders almost always coincide, excepting 
that in marked dilatation the absorption of the products of fer- 
mentation and the consequent low forms of poisoning may be prom- 
inent. In both the same signs of vomiting, constipation and 



DISEASES OF THE STOMACH AXD SMALL LXTESTTXE 129 

diarrhoea, headache, coated tongue, malnutrition, lack of appetite, 
and general weakness may be present. In dilatation the vomiting 
may be more pronounced and in older children the appetite may be 
somewhat better, especially at intervals, when the stomach has been 
emptied. The main differential symptom is furnished by percus- 
sion. This, if carefully practised about three hours after eating, 
gives a tympanic note nearly to or even below the umbilicus. 
One's opinion in the matter may be verified by filling the stomach 
with water, percussing anew, and noting the quantity of water 
used. Carefulness in such ways will prevent confusing a dilated 
stomach with a dilated transverse colon. There is always a dan- 
ger of such confusion, because in both conditions, especially if the 
patient has thin, weak body walls, there may be a prominence in 
and below the epigastric region, with tenderness on pressure. 

Treatment. — The treatment is likewise similar to that of 
chronic gastritis. The stomach should be washed out every day, 
in older children before the principal meal. The diet should be 
restricted in quantity and variety of food. For infants, albumin 
water, beef extract, and diluted milk may be given in smaller 
amounts and at longer intervals than a normal baby demands. 
Older children may have diluted milk, clear meat soups, scraped 
beef, and dry toast. As they improve, this diet may be enlarged 
by the addition of broiled steaks and chops with some easily di- 
gested fresh vegetable. Considerable help may be obtained by 
the liberal use of mix vomica or strychnine with the addition, 
when improvement sets in, of an organic preparation of iron. 

A wise regulation of exercise, of the hygienic and sanitary ar- 
rangements as well as the general mode of life is of the utmost 
importance. 

Prognosis. — The outlook is fairly good, excepting where the 
condition is dependent upon an organic pathological condition 
which, like stenosis of the pylorus, does not easily permit of cure. 
The chances of recovery are better in children than in adults. 

Ulcer of the Stomach 

Causes. — Although gastric ulcer is rare, it is nevertheless apt to 
appear at any time, in all classes of patients and at any age. The 
cause in most cases is obscure. An ulcer may be present at birth; 
on autopsy it has been found in cases of the hemorrhagic diseases of 



^H 



130 THE MEDICAL DISEASES OF CHILDHOOD 

the new-born ; it may occur in chronic gastritis where a portion of 
the mucous membrane becomes injured or loses its full blood sup- 
ply. Or it may be the result of tubercular deposit and degenera- 
tion. In other rare cases, the small pus-foci of suppurative gastritis 
may coalesce and form a large ulcer. The round perforating ulcer 
has generally a mysterious aetiology; the most logical explanation 
lies in an embolism of the gastric arteries or their branches by 
which the vitality of any part is so far debased that necrosis may 
occur ; the lesion naturally would be exaggerated by the action of 
the gastric secretions upon the devitalized spot. In somewhat the 
same way an embolism of the umbilical vein after birth might in- 
directly cause an ulcer of the stomach. In all cases one must 
reckon on having an exhausted physical condition as a precedent 
fact. Purpura hsemorrhagica may be a predisposing factor. 

Lesions. — These vary according to the child's vitality and 
the individual disposition of the disease. Sometimes the mucous 
membrane alone is attacked ; again, the successive tissues are 
eaten through so that the opening extends through the peritoneal 
coats. In some cases the hole looks as if made by an instrument ; 
in others it slopes like a funnel, the large end being in the mucous 
membrane. These latter have a margin that may be in a condi- 
tion of intense congestion or even necrosis. The surrounding area 
is usually much congested, although occasionally it is fairly nor- 
mal. No especial portion may be assigned as a favorite location. 

Symptoms. — The signs are obscure. There may be diarrhoea 
and vomiting, the latter being the more prominent. In the vomitus 
may be variable quantities of blood, or, if a large artery breaks 
down, there may be a vomiting of clear blood. In such cases, as 
well as in some of those where the hsemorrhage is not so great, 
blood will be found in the stools. In some cases there are pain, 
tenderness on pressure, and active signs of disorders of digestion, 
which are especially prominent shortly after taking food. In 
others the symptoms may come on suddenly and with few pre- 
monitory signs. 

The temperature varies so much that no characteristic course 
can be given ; at times it is slightly raised, but at others it is very 
high. If perforation occurs, it may drop to subnormal ; in the 
presence of shock this may be maintained, but if the child sur- 
vives long enough to undergo a peritonitis, the fever may again 
rise very high. In a considerable proportion of the cases a sten- 
osis of the pylorus is apt to result. 



DISEASES OF THE STOMACH AXD SMALL IXTESTIXE 131 

Treatment. — Very little can be done for these cases. One 
should order complete rest, shonld give ice, and small doses of 
opium. Nourishment is best given in the form of peptonized milk 
or beef extract by rectum. Direct medication of the stomach is 
of questionable value. 

Prognosis. — The outlook is bad. 

hemorrhagic erosioxs of the gastric mucous 
Membrane 

In debilitated children of any age the mucous membrane, gen- 
erally in the region of the pylorus, may become eroded. Outside 
of debility no cause is known. The destruction of tissue is super- 
ficial, and the only symptoms are irritability, pain, disordered di- 
gestion, and blood-streaked vomitus. 

There is no method of ascertaining the existence of this condi- 
tion except by autopsy. Consequently no treatment can be pre- 
scribed. 

Gastealgia 

Gastralgia is a functional irritation of the peripheral nerves in 
and about the stomach, whose main expression is pain in various 
degrees. What its cause is, outside of local and general atony, 
has never been fully demonstrated. It may be associated with 
organic diseases or be entirely divorced from them. The stomach 
and epigastrium may be hard and contracted. The pain is situ- 
ated in the epigastrium and may be sharp, heavy, or spasmodic. 
It is, apt to be periodic, in many cases it appears at night, and 
may occur when the stomach is empty or full. When it exists in 
a pure form there is no necessary rise of temperature, but there 
may or may not be considerable depression. It may come sud- 
denly and leave as quickly. 

Treatment. — Before adopting means of relief, one should be 
sure that there is no complicating gastritis or gastric ulcer, whose 
treatment would deserve consideration. Uncomplicated gastralgia 
may be relieved by rest in bed, the application of a hot water bag, 
and the administration of a few doses of antipyrin in combination 
with aromatic spirits of ammonia. The antipyrin may be given in 
doses of 0.06 gm. (1 gr.) for each year of age up to 0.3 gm. (5 gr.). 

Some persons seem predisposed to successive attacks of this 



mmam^^mt^BU^mmaam 



132 THE MEDICAL DISEASES OF CHILDHOOD 

disorder. Strict attention to the general health and a wise regu- 
lation of daily life are the best preventives. 

H.EMATEMESIS 

This is a symptom that may occur without discoverable lesions. 
It is sometimes seen in the newly born, in " bleeders " (haemophi- 
liacs), in purpura hemorrhagica, in scorbutus, in malaria, in pro- 
found anaemia, in vicarious menstruation, in trauma, in malignant 
forms of the acute infectious diseases. The blood may or may not 
appear in the stools. 

One should be careful not to be deceived by blood which was 
swallowed, either in haemorrhage of the mouth, nose, or throat, or 
from a cracked nipple. Likewise the distinction between haema- 
temesis and haemoptysis must be made. In the latter the blood 
is bright red, frothy, mixed with mucus ; in the former it has a 
dark color, is thick, and commonly is accompanied by various 
quantities and sorts of food. 

The treatment includes rest, the use of ice, and at times opium 
in small doses. Stimulants may be given hypodermically. 

The prognosis varies with the cause and circumstances of each 
case. 

Duodenitis 

An inflammation of the duodenum may occur alone, but as a 
rule it spreads in some further direction, or is the result of a com- 
munication from a neighboring part. In this way we may find 
the stomach and duodenum associated, or the duodenum and com- 
mon bile-duct, or the duodenum and the rest of the small intes- 
tine. As an example, an acute gastritis may be followed by an 
acute gastro-duodenitis, or ulcer of the stomach by ulcer of the 
duodenum. An irritant poison will not necessarily confine itself 
to the stomach, but may affect the whole or any part of the small 
intestine as well. There are even a few seemingly mysterious 
cases on record where severe burns of the skin, which destroy 
the vaso-motor nerve filaments in the skin and thus bring about 
deep-seated congestions, have been followed by the formation 
of ulcers in the duodenum, or ileum, or both. As a rule, the 
inflammation that one finds is catarrhal, with varying degrees 
of congestion of the mucous membrane, and the over-production 
of mucus. The only symptoms that one can trace are pain, 



DISEASES OF THE STOMACH AND SMALL INTESTINE 133 

vomiting, constipation or diarrhoea, some elevation of temper- 
ature, and a moderate degree of prostration. Usually, since a 
neighboring organ is involved, there will be present the symptoms 
of such extension. Thus one may see the jaundice that follows 
inflammation of the common bile-duct or the swelling of the soli- 
tary and agminated glands in the ileum. This last complication 
constitutes one of the dangers of the duodenitis ; for these glands 
may, after swelling, soften and break down. The ulcers that re- 
sult may be of any depth, may even perforate the intestinal wall, 
causing peritonitis and death. 

The treatment of duodenitis is usually combined with that of 
the associated disease. In itself it includes rest in bed, cathar- 
sis by means of a saline or calomel followed by a saline, and the 
restrictions of the diet to fluids. The possibility of a sharp dif- 
ferential diagnosis is limited by the fact that the disease is almost 
always an extension of a gastritis or enteritis. 

The prognosis, except in case of serious involvement of neigh- 
boring organs, is good. 

Chronic Duodenitis 

This disease is one that is often enough seen, but not as often 
recognized. It so readily suggests disease of the large intestine, 
and in the resulting confusion has received so many different 
names, that many practitioners are not to be blamed for regarding 
it as somewhat obscure. It has been called chronic gastrointes- 
tinal catarrh, chronic gastro-duodenal catarrh, mucous disease, 
chronic pseudo-membranous gastro-enteritis, chronic muco-colitis, 
intestinal desquamative catarrh, and several other names. 

Causes. — Its aetiology is hard to determine ; no micro-organism 
has been definitely associated with it, nor has any clearly defined 
connection been shown with a recognized form of intestinal 
abuse. Thus one can have much sympathy with the older views 
which regarded it as the product of an intestinal neurosis. 
As a matter of fact, we know that it is likely to follow 
an exhausting sickness or a debilitated condition. Moreover, a 
child that has a bad diet for weeks and months is liable sooner or 
later to be afflicted with this disease. In addition, the acidulated 
chyme of gastric hyperacidity or the alkaline fermentation of 
gastric anacidity is sufficient to set up an irritation in the duo- 
denum that may run a chronic course. Still there are occasional 



uam^^m^^^mmmuM^mmmmm 



131 THE MEDICAL DISEASES OF CHILDHOOD 

cases which simply baffle an inquiry into their origin. There is 
the same uncertainty in regard to the age at which the disease 
usually occurs. Thus, as a rule, it is seen in children from four 
years up to ten or twelve. Nevertheless, one of the most obsti- 
nate examples of it that I have seen was in a baby of fifteen 
months who had had the advantages of reasonably good care. 

Lesions. — The changes at first occur in the duodenum. From 
there they may spread to the rest of the intestine or the stomach. 
The mucous membrane is congested, thick and heavy, and pours 
out a large amount of mucus. The glands and follicles may be 
swollen and in marked cases may break down and ulcerate. 

Symptoms. — The disease is apt to begin in a subacute manner, 
and the child suffers a series of intestinal or gastro-intestinal dis- 
orders. At the same time the general nutrition is debased, the 
nervous equilibrium is poor, and invasion by intercurrent diseases 
is weakly resisted. The temperature never runs very high except- 
ing when an acute exacerbation occurs. The patient looks depressed 
and run down, his tongue may be somewhat coated, or dotted with 
shallow aphthous ulcerations, or may merely be red and shiny. The 
nose and throat may, doubtless as a result of debility, be the seat of 
catarrhal inflammation. There may be tenderness and pain in the 
left hypochondrium and abdomen, which run an irregular course. 

Occasionally there are gastric disturbances, but not so fre- 
quently as disorders of the intestines. These latter appear in the 
form of constipation or diarrhoea, oftener the latter. Both may 
be accompanied by the discharge of mucus, whose amount is strik- 
ingly and abnormally large. Sometimes this comes in masses, 
more often it is worked all through the movement ; again it con- 
stitutes the whole movement, replacing all faeces. The faecal 
movements are often characteristically clay-colored. 

As the disease progresses, especially in the absence of wise 
efforts to uphold nutrition, the child becomes emaciated, his skin 
turns dry and harsh, and nervous symptoms become pronounced. 
Hysteria and disturbances of the sense-functions present manifold 
symptoms which may blindly mislead the relatives as well as the 
physician. Under such circumstances subjective impressions upon 
the child and temporary moral defects are common. In other 
cases, attacks of skin diseases — dermatitis, eczema, and herpes 
of the lips and genitals — add their influence to make confusion. 

No matter how many related symptoms exist, if the attention 



DISEASES OF THE STOMACH AND SMALL INTESTINE 135 

is fixed upon the characteristic signs, one will usually make a 
correct diagnosis. These are the chronic course, the mental 
irritability, the clay-colored stools and abnormal amounts of 
mucus, the dry, harsh skin, the abnormal tenderness, pain, and 
distension, the intestinal irregularity and lack of high tempera- 
ture. If these are kept in mind, one will not be deceived into 
naming intestinal parasites, tuberculosis, or nervous disorders as 
the basis of the disease. 

Treatment. — The care of these cases demands the utmost vigi- 
lance, judgment, and tact. Intestinal antiseptics are useless, astrin- 
gents are even harmful. The main reliance should be put upon the 
stimulants and tonics, and of these nux vomica or strychnine is 
the chief. Other drugs may from time to time be needed, such 
as bismuth subgallate for diarrhoea, calomel or citrate of magnesia 
for constipation, or small doses of opium for pain. The nose and 
throat may require alkaline douches, the skin may need massage, 
and every detail of hygienic and sanitary management must be 
carefully supervised. Whenever the weather permits, the patient 
should be in the air as long as possible, the bedroom and the nur- 
sery must be cheerful and well ventilated, and the clothing proper 
in quality and weight. One of the most important items of treat- 
ment is the diet. This must as far as possible admit proteids and 
exclude sugars and starches. Milk, if possible, should be ex- 
cluded; if it cannot be, then it should at least be diluted enough 
to make a weak cream and sugar percentage. In addition one 
may order clear meat soups, beef extract, lean meats, soft-boiled 
or poached eggs, and dry toast. Much food may not be given at 
one time ; therefore it may be advisable, even for well-advanced 
children, to have four small, instead of three large, meals per day. 
The patient each day should have a cool bath, which is to be 
followed by vigorous friction. 

As the child shows improvement, the nux vomica or strych- 
nine may be supplemented by small doses of an organic prepara- 
tion of iron. 

Prognosis. — The outlook must include a fairly long course 
with a fairly certain recovery. Parents must be warned that 
infringement of the diet will, in all probability, mean a relapse, 
and that this diet must be maintained until the child is free 
from mucous stools. Recovery will be hastened by avoiding a 
too free or indiscriminate medication. 



CHAPTER IX 
DISEASES OF THE PANCREAS, LIVER, AND SPLEEN 

The Pancreas 

The main pathological condition which one meets in children 
is the acute parenchymatous pancreatitis which occurs with the 
acute infectious diseases. This is characterized by congestion 
and swelling and a degeneration of the epithelial tissue. When 
convalescence is chronically retarded, there may be a formation of 
new connective tissue. 

There may be a fatty or an amyloid degeneration of the pan- 
creas which occurs when a similar process attacks other viscera, 
such as the liver or the spleen. The causes and course of the 
changes are the same in all. 

Icterus 

Icterus, commonly called jaundice, is a yellow coloration of the 
sclerotic membrane, mucous membrane, and skin, caused by the 
absorption of bile pigment. It is a symptom which has in some 
cases no pathological importance ; in others it may accompany 
serious organic changes. The simple form seen at birth is said to 
arise from a disturbance of the circulatory equilibrium which ac- 
companies the infant's entrance into life. At the same time con- 
genital obliteration of the cystic and hepatic ducts, either above 
or below their junction, can bring about the same result. Other 
varieties of obstruction may be caused, in rare cases, through the 
plugging of a duct by a round worm, by congestion of the lining 
membrane of the duct, or by pressure resulting from organic dis- 
ease and growths in adjacent structures. Outside of these hepa- 
togenous forms, there are some non-obstructive or hematogenous 
cases produced by malaria, pyogenic inflammation of the umbili- 
cal vein, gastro-enteritis, pyaemia, yellow fever, Winckel's disease, 
Buhl's disease, syphilis, the inhalation of large quantities of ether 
or chloroform, and poisoning by certain metals, such as phosphorus. 

136 



DISEASES OF THE PANCREAS, LIVER, AND SPLEEN" 137 

Some animal and vegetable poisons at times bring about the same 
result, but the action is not regular and inevitable. 

The treatment varies according to the cause ; in icterus neona- 
torum no treatment is necessary. The discoloration occurs within 
three days after birth and may persist for one or two weeks. 

Functional Derangements of the Liver 

These derangements are but little understood, and, moreover, are 
very hard to investigate. They should not be classed among fatal 




Fig. 9. —Normal Liver. X 50. 

diseases, and although they are not rare during life, nevertheless 
one is not often able to find them in post-mortem examinations, ex- 
cepting under such circumstances as would at all events interfere 
with the normal function and structure of the liver. 

The usual symptoms that we associate with hepatic functional 
derangements are hard to differentiate sharply from those of de- 
rangements of the small intestine. The stools are apt to be hard 
and gray, and there may be evidences of much decomposition of 
intestinal contents, with the consequent absorption of products of 
putrefaction, and there may or may not be some degree of jaun- 



138 THE MEDICAL DISEASES OF CHILDHOOD 

dice. Children react quickly and fully to such intoxication, 
mentally as well as physically. I believe that many abnormal 
psychical states, many instances of viciousness, of rebellion against 
control maybe — as I have stated in a former publication — traced 
to some error in nutrition, such as hepatic derangement; and, 
doubtless, more frequently to it than to any other allied disorder. 
The usual treatment consists in free catharsis by means of 
calomel and a saline cathartic, joined with rest in bed, and a strict 
confinement of the diet to fluids. Frequent warm baths will 
prove to be of considerable value. 

Congestion of the Liver 

This disorder may occur in two forms which from their aetiology 
one may call primary and secondary. The first occurs as the 
result of errors in diet, especially where the child has been allowed 
to have rich and spiced foods or alcohol in comparatively large 
doses. Malnutrition, or the existence of prostrating heat, renders 
him still more liable to the disorder. The secondary form follows 
chronic malarial poisoning, scurvy, syphilis, emphysema, pleurisy 
with effusion, valvular diseases of the heart, and abnormal condi- 
tions producing pressure upon the vena cava. 

The result is an enlargement of the liver, except in very long- 
continued cases. This enlargement is easily made out by percus- 
sion and palpation. The microscopical changes are those of con- 
gestion in the acini followed, if the process be protracted, by fatty 
degeneration. 

In addition to the enlargement of the liver, there is generally, 
although not always, some jaundice. It is not difficult to convince 
oneself whether the congestion is primary or secondary, although in 
both cases symptoms of gastro-ihtestinal derangement are present. 

The treatment in both cases requires the careful regulation of 
diet, cutting off of rich and highly seasoned food, decrease or 
elimination of alcohols, and the administration of calomel, followed 
by small and repeated doses of saline cathartics. The later use of 
acids and intestinal tonics is advisable. In this disorder the com- 
pound mixture of rhubarb and soda, one teaspoonful thrice daily 
for a child of six years, has value. If the congestion is syphilitic, 
it will yield to the specific treatment as given in the section on 
syphilis. 



DISEASES OF THE PANCREAS, LIVER, AND SPLEEN 139 

Parenchymatous Hepatitis 

In the presence of certain pathological conditions the liver, as 
well as other viscera, becomes acutely affected with parenchyma- 
tous degeneration. These conditions are, for the most part, the 
acute infectious fevers, such as diphtheria, scarlet fever, acute lobar 
pneumonia, typhoid and typhus fevers, measles, chicken-pox, and 
yellow fever. Other diseases which are characterized by marked 
toxic effects, such as septicaemia and erysipelas, may bring about 
the same result. 

When this degeneration happens, the organ increases in size 
and loses something of its characteristic formation. The hepatic 
cells become congested, swollen, and choked up, and may start in 
a process of deterioration and breaking down. Under conditions 
of faulty environment and nutrition, the parenchymatous hepa- 
titis may be followed by a state of fatty infiltration with a con- 
sequent destruction of structure. 

The symptoms, when they are recognized, are usually classified 
under disorders of the stomach and small intestine. The treat- 
ment, outside of what the original disease demands, consists in 
the strict regulation of diet and enforced inactivity. The main 
danger in the disease is the possibility of forming an unlooked- 
for complication of the original sickness. 

Purulext Hepatitis 

Purulent inflammation of the liver may result directly from 
an injury or indirectly from an antecedent infecting cause. In 
the latter case many different sources may be responsible for the 
injury. Even if the original focus of suppuration is far removed 
from the liver, the general circulation is always able to act as an 
efficient vehicle. Thus, not only have septic inflammations of 
the gall-ducts and portal veins been the starting-point, but also 
septic processes of the umbilical vein, ulcers of the stomach, para- 
sites from the intestine, typhoid fever, ileo-colitis, appendicitis, 
and other intestinal ulcers have accomplished the same result. 

When such a purulent inflammation has been set in motion, it 
regularly culminates in an abscess. Excepting after traumatism, 
the abscesses are usually multiple, but by their confluence they 
form one large mass. As the pus approaches the surface, the re- 



140 THE MEDICAL DISEASES OF CHILDHOOD 

sistance becomes less until perforation occurs into intestines, peri- 
tonaeum, stomach, lungs, pleura, pericardium, or through the chest 
wall. The metastatic abscesses of pyaemia have the same natural 
history as those in other parts of the body. 

Symptoms. — Where there is a history of trauma, the child 
will immediately suffer from pain and possibly from shock. The 
characteristic signs of suppuration may not show themselves for 
some days. Then pain is apt to reappear, the child may have a 
chill, and the temperature will rise. Where the cause depends 
upon a previous pathological condition, the symptoms of such 
disease are naturally first seen, and those due to the involvement 
appear later as a sequel or complication. At times the condition 
is confusing, but the main things which one must keep in mind 
are the local symptoms of pain and tenderness and those of sup- 
puration. There is almost always an increase in the size of the 
liver, which most often may be noticed below the free border of 
the ribs. If the increase in size is directed toward other viscera, 
the pressure will produce corresponding signs in proportion to its 
extent. In addition there will be pain over the liver, over the 
abdomen, in the chest, or even in the right shoulder; generally 
there is tenderness in the hepatic region, although its location 
does not inevitably define the position of the abscess. The tem- 
perature is irregular, intermittent, or remittent. There may be 
an initial chill or daily chills. The prostration increases, wast- 
ing becomes marked, and in many cases jaundice appears in vary- 
ing degrees. As the sickness becomes more profound, stupor 
and delirium supervene, and the picture becomes one of pyogenic 
intoxication and rapid decline. 

Differential Diagnosis. — In the event of trauma to or about the 
liver, the history of the case immediately directs the attention to 
the possibility of a pus-process in this region. But in the other 
cases the diagnosis is apt to be more obscure, and at times must 
be made by exclusion. If there are signs of pus, and if other 
localities are evidently clear, one should explore the liver with an 
aspirator or hypodermatic syringe in the attempt to find pus. A 
failure to find it is no conclusive proof that it does not exist ; and 
one should always remember the intimate relations, as far as symp- 
toms go, that exist between purulent hepatitis, pus in the right 
pleural cavity, and right diaphragmatic or subdiaphragmatic ab- 
scess. In a fair proportion of cases it is practically impossible to 



DISEASES OF THE PANCREAS, LIVER, AND SPLEEN 141 

locate the lesion without definite exploratory evidence. Usually 
one can without much hesitation distinguish purulent hepatitis 
from the enlarged liver that occurs with cardiac disease, tumors, 
syphilis, or hypertrophic cirrhosis. For the combination of chills, 
local pain, the irregular temperature, and the general picture of 
developing sepsis prevents confusion. 

Treatment. — These cases should be referred to a surgeon as 
soon as the diagnosis is made. The sooner they are operated 
upon, the better are their chances for recovery. Under such 
measures a large majority of the cases may be saved. In all 
events, the course of the case is apt to be protracted, and the 
child may not regain his health for weeks or months. 

Interstitial Hepatitis 

Causes. — This disease is generally regarded as belonging to 
adult life ; and it is practically never seen in the first half of 









Fig. 10. — Hypertrophic Cirrhosis of the Liver (early stage). X 55. 

childhood ; nevertheless, as with other rare sicknesses, instances 
of it occur occasionally, but steadily, in hospital practice. The 
causation is very obscure, for in children one has not the ready 
recourse to alcoholic and other excesses to which adults are 




142 



THE MEDICAL DISEASES OF CHILDHOOD 



addicted. Thus very few of the children who suffer from cir- 
rhosis give a history of alcoholic excess ; a few are congenitally 
s} 7 philitic, and a few more have suffered from severe or wasting 
disease. The most that one can say is that this complaint is a 
vicious form of deflected nutrition whose explanation is at present 
obscure. 

Lesions. — The characteristic feature of the changes is a depo- 
sition of connective tissue in the liver. When the process begins, 
its course is more rapid than in adults, although the main char- 
acters are alike. The new tissue grows in various shapes and in 
all parts of the organ, and by pressure squeezes and chokes the 





JK 



* f * - \ 4 




^|j|i 



Fig. 11. — Interstitial Hepatitis. X 125. 

hepatic cells. The blood-vessels, especially the hepatic and 
portal veins and their branches, as well as the gall-ducts, later 
on become attacked, so that their elasticity is sufficiently encroached 
upon to become progressively functionless, while the lumen regu- 
larly grows smaller. In addition, the bile-ducts may fall into a 
catarrhal inflammation, the hepatic tissue may become subject to 
amyloid or fatty degeneration, and the whole organ may become 
bound by adhesions to near-by structures. 

Secondary changes occur in the later stages : the veins about 
the umbilicus, or all the abdominal veins may become enlarged ; 
the spleen may become hypertrophied, the stomach and intestines 
may show the symptoms of a catarrhal inflammation, or may even 



DISEASES OF THE PANCREAS, LIVER, AXD SPLEEX 143 

have considerable haemorrhages. Ascites and a chronic intersti- 
tial nephritis characterize the final stages of the disease. 

Symptoms. — The course of the disease is so insidious that, 
unless the liver is carefully palpated, its true nature is often 
unsuspected until far advanced. The first enlargement of the 
liver then changes to an unduly small size, the child begins to 
waste away, gastrointestinal disorders of various kinds appear, 
and the skin may assume a yellow discoloration. As the malnu- 
trition becomes more marked, ascites appears, and usually is 
accompanied by disturbances of various abdominal and thoracic 
viscera. These cases are very hard to nourish, and the process 
of wasting progresses with rapid strides. This disease is a good 
example of the general truth that degenerative processes in chil- 
dren are much quicker in their course than in adults. 

The distinction between this disease and acute yellow atrophy 
of the liver is at times difficult. In interstitial hepatitis the course 
is ever so much longer, and one stage fades into the other by in- 
sensible degrees. In atrophy the progress is comparatively rapid. 
In the first the symptoms are more clearly referable to the liver, 
and therefore less to the general organism than in the second. 
Also, in the first, the form of the organ can be well discerned as 
being large in the beginning, then smaller and at all times fairly 
hard and regular, with a moderately sharp lower margin. In 
atrophy there is a tendency to softness of consistency, irregular 
contour and blunted or indistinct lower edge. The extreme 
rarity of the second disease must alwa}*s remain a factor of diag- 
nostication. 

Treatment. — The most that one can do is to regulate the diet 
and treat the symptoms. Attention to every detail of the child's 
hygienic and medicinal care may delay the fatal outcome. The 
diet must be simple and nutritious ; some form of gentle exercise 
in the open air should be taken as long as the child's condition 
permits ; the action of the bowels and kidneys should be kept as 
clear as possible ; bathing should be regular. In some cases one 
may use tonics with beneficial effect. 

Acute Yellow Atrophy of the Liter 

Acute yellow atrophy is an exceedingly rare disease in chil- 
dren. It is hard to say whether it is primarily a disease of the 



144 THE MEDICAL DISEASES OF CHILDHOOD 

liver or of the general economy. At all events, the lesions are 
not found alone in the liver but in the other abdominal and tho- 
racic viscera as well. It may be classified under the heading of 
obscure wasting diseases. 

The liver, though at first enlarged, becomes diminished in size, 
is soft and wrinkled. The characteristic structure fades away, 
and is replaced by a condition of fatty degeneration. The tissue 
is colored by the presence of yellow or reddish-yellow pigment 
that increases in quantity as the disease progresses. Small quan- 
tities of leucin and tyrosin may be found in the broken-down cells, 
and the interstitial tissue wastes and fades away. In the final 
stage, the liver is practically a shapeless mass. 

Ik 






•=.- 



x^r # 



Fig. 12. — Acute Yellow Atrophy of the Liver. X 100. 

The symptoms consist in a general way of steady malnutrition, 
prostration, gradual starvation. Usually there is jaundice, and 
cerebral disorders may supervene. 

The treatment is symptomatic. The outcome is death. 

Fatty Liver 

The normal liver contains some fat which may vary from time 
to time. In the presence of severe wasting diseases, such as ma- 



DISEASES OF THE PANCREAS, LIVER, AND SPLEEN 145 

rasmus, chronic ileocolitis, tuberculosis, profound anaemia, and 
phosphorus poisoning, this amount of fat may be very largely 
increased. The infiltration begins at the periphery, and requires 
a considerable time to get to the centre. Thus, on section, the 
tissue near the surface may be a light yellow, while the centre has 
a reddish color. The fat may be so plentiful that the cut surface 
is greasy. 

The condition is recognized by the history of previous disease, 
the discovery of a large liver with rounded edges, and the absence 
of hepatic symptoms. 




Fig. 13. — Fatty Liver. X 180. 

The treatment is that of the primary disease, and the regula- 
tion of the diet and hygienic conditions. The patient should be 
in the air as much as possible, must bathe regularly, and should 
take tonics. 



Amyloid Degeneration of the Liver 

A waxy liver rarely occurs without a concurrent similar con- 
dition in the kidneys, spleen, intestines, or other viscera. One's 
attention is thus drawn to the fact that this degeneration is not a 
local disease so much as a local expression of a general affection. 
It arises from conditions of marked exhaustion, from wasting, dia- 



146 THE MEDICAL DISEASES OF CHILDHOOD 

thetic and osseous diseases, from chronic suppurative processes, 
from such complaints as chronic tuberculosis and congenital 
syphilis. 

The process usually begins in the intralobular arterioles, which 
become thick and waxy. Later, it attacks other vessels and then 
the liver tissue. The affected parts lose their characteristic struc- 
ture, become light brown in color, hard, smooth, and translucent. 
The size of the organ is much increased, and the margin is hard 
and sharp. The size may be restrained in its growth if cirrhosis 
develops to any considerable extent. In addition, there may be 
areas of fatty infiltration. 






w>^y<- 



Fig. 14. — Amyloid Degeneration of the Liver. X 60. 

The condition practically never appears alone ; especially,, 
should one look for amyloid conditions in the kidneys. These 
symptoms, with the history of the original sickness, are fairly sure 
to make the diagnosis clear. There are rarely any liver symptoms, 
and the exceptional cases of jaundice or ascites can generally be 
explained on the score of pressure. The patient's skin has a pe- 
culiar waxy appearance that is noteworthy. The disease does 
not cause pain. 

The treatment is that of the original disease. Although the 



DISEASES OF THE PANCREAS, LIVER, AND SPLEEN 147 

prognosis is not encouraging, nevertheless, I believe that with 
careful and vigorous treatment of the general condition much can 
be done for the child's comfort and well-being. By means of a 
carefully regulated diet, tonics, and whatever exercise is possible, 
the functional activity of the body may be prolonged for an 
indefinite time. The treatment of such a case is a matter of 
details, the aggregation of which makes a general impression. 
The growth of the disease is so gradual that one usually has 
months at one's disposal before the case becomes hopeless. 



Echinococcus Infection of the Liver 

This infection is due to the taenia echinococcus or dog tape- 
worm. When the eggs of the parasite find their way into the in- 
testinal canal they begin to develop. They then penetrate various 
organs, but most frequently the liver, where they produce cysts, 
called hydatids. From them secondary or daughter cysts may 
grow, and in turn may give off tertiary or grand-daughter cysts. 
Each cyst has a connective tissue capsule in two layers ; and on the 
lining membrane the heads or scoleces of the young taenia are pro- 
duced. Each scolex has a rostellum placed in the middle of two 
rows of hooklets and four sucking plates. The cysts contain a 
fluid of low specific gravity, of an alkaline reaction, containing al- 
bumin, sugar, sodium chloride, and cholesterin crystals. In the 
fertile cysts the fluid is made less clear by the pressure of scoleces, 
hooklets, and fragments of parenchymatous tissue. 

Symptoms. — In children the cysts are generally unilocular. 
Their growth is so slow that months may pass before their press- 
ure attracts attention. This happens the easier because they 
rarely cause pain, high temperature, or pressure effects. When 
this last-named symptom exists, it shows itself in whatever di- 
rection the growth takes. Thus the right lung and pleural cav- 
ity may be encroached upon, or the abdomen or heart and great 
vessels be affected. In many cases the swelling can be made out 
by palpation, and in a few, one may distinguish the "hydatid 
fremitus " by placing the left hand on the tumor and tapping a 
near-by part of the liver with the right. 

Jaundice may occur from pressure ; nevertheless, the general 
health is, as a rule, unaffected. This rule does not hold, o£ course, 
if suppuration sets in. 



■M 



148 THE MEDICAL DISEASES OF CHILDHOOD 

Treatment. — The treatment is surgical : when properly and 
thoroughly accomplished, the prognosis is fairly good. Delay 
means ultimate rupture, either externally or into one of the tho- 
racic or abdominal viscera ; when rupture is internal the result is 
usually fatal. 

Differential Diagnosis. — Hydatids are to be distinguished from 
syphilitic and carcinomatous diseases of the liver. As a rule this 
is not difficult, as the latter disorders have characteristic histories, 
carcinoma especially making general and systemic inroads upon 
the patient's health. The diagnosis is certified by aspirating the 
tumor and finding hooklets. 

Wounds of the Liver 

Wounds of the liver may be caused by artificial and very 
difficult delivery, or by falls or blows. They may be of various 
degrees of severity, and are usually followed by inflammation or 
abscess. The most serious cases usually involve a rupture of the 
capsule as well as the parenchyma. Here there would be a large 
and fatal haemorrhage. In all cases of wounds there is more or 
less bleeding, which in children is always dangerous. Extravasa- 
tions of blood in the liver may result from hard delivery, scor- 
butus, the administration of poisonous quantities of phosphorus, 
and from purpura hemorrhagica. 

The portal vein may be injured by blows and falls. The 
result may be endophlebitis and the formation of a thrombus ; 
marked changes in the functional equilibrium of the abdominal 
viscera may make themselves apparent 

Subphrenic Abscess 

As a result of pus infection an abscess may form between the 
liver and diaphragm. From its position it is called subphrenic. 
The original focus of pus may be in the liver, intestines, stomach, 
lungs, pleura, or other near-by viscera ; in another class of cases, 
which is rarely seen, the pus may come after the rupture of an 
hydatid cyst of the liver. The infection may in others be com- 
municated through the lymph circulation from a fairly remote 
source, such as the skin of the glands. Thus, I may cite a case 
which I saw where a very severe furuncle in the back was fol- 
lowed by a subphrenic abscess. There was much difficulty and 
several failures before the correct diagnosis was made. 



DISEASES OF THE PANCREAS, LIVER, AND SPLEEN 149 

The symptoms resemble those of purulent pleuritis of the right 
side. The diagnosis may be confirmed by the aspirating needle. 
The treatment is free opening and drainage. 

Biliary Calculi 

In childhood gall-stones are so rare as to require no more than 
a mention. They have been found at all ages, and no matter 
what the time of life the symptoms are always the same. During 
the attacks sedatives should be administered in sufficient quantity 
to quiet pain. After the attack has passed phosphate of sodium 
in large doses may be prescribed. These children should drink a 
generous amount of water. 

Congestion of the Spleen 

Congestion may occur simply as a hyperemia, or as an active 
inflammatory process. This is the condition that accompanies 




Fig. 15.— Normal Spleen. X 100. 

the acute infectious diseases, such as scarlet fever, measles, acute 
lobar pneumonia, typhoid and typhus fever, diphtheria, and in 
the severe diseases of pyogenic invasion, as septicaemia and py- 
aemia. In malaria, especially of a pronounced form, it may be 



150 THE MEDICAL DISEASES OF CHILDHOOD 

present in a marked degree ; in diseases of malnutrition, such as 
rickets, and in systemic disorders, such as syphilis, tuberculosis, 
and blood diseases, it may be looked for more regularly in children 
than in adults. 

Lesions. — The size of the organ is increased, the cavernous 
veins surcharged with blood, the pulp tissue has a deep red color, 
is spongy, soft, and of an unstable consistency. In severe cases, 
or those characterized by large amounts of toxines, there is a 
marked increase in the cell tissue, or a noticeable hyperplasia 
in the glomeruli. Where vitality is deficient there may be a con- 
sequent degeneration of this tissue, or even a necrotic breaking 




Fig. 16. — Congested Cavernous Vein of Spleen, x 70, 

down into small abscesses. When convalescence takes place the 
congestion fades away, and the products of degeneration are ab- 
sorbed. When recovery is delayed too long, the small foci of 
suppuration may increase and flow together, forming an abscess ; 
or the hyperplasia may give way to a formation of connective tissue. 
There is no special treatment for these diseases of the spleen 
outside of the treatment of the original disorders, which must be 
continued until one is sure that the organ is practically restored 
to its normal usefulness. For a considerable period the spleen 
must be regarded as liable to revert to its pathological condition. 



DISEASES OF THE PANCREAS, L1VEK, AND SPLEEN 151 



Amyloid Degeneration of the Spleen 

There may be a waxy degeneration of the blood-vessels and 
reticulum, or of the glomeruli, or of the pulp tissue. Occasionally 
the process is practically general. The organ is much increased 
in size, is hard, and the edges are rounded. The process rarely 
occurs alone, but usually is associated with similar changes in 
other viscera, especially the liver. The cause seems to be marked 
malnutrition and lack of systemic vitality. The treatment is that 
of the general condition and includes a careful diet, gentle exer- 
cise, baths and tonics. 

Parasites of the Spleen 

Echinococcus sometimes attacks the spleen. And cysticercus, 
as well as pentastomum denticulatum, is found. Various bacteria 
have likewise been found when an infectious disease was attacking 
the body. 





i^Sp^* - 



mm,. 



^m- 



■ Vif'-:-:.. : : 





Fig. 17. — Chronic Interstitial Splenitis (Sago Spleen), x 60. 



Wounds of the Spleex 

Wounds of the spleen are always serious, no matter what 
their extent may be. The peculiar structure of the organ is 



152 THE MEDICAL DISEASES OF CHILDHOOD 

partly responsible for this, since the pulp-tissue serves in place of 
the blood-vessels which are found in greater quantity in other vis- 
cera. Thus, a wound of the spleen involves at one time both the 
vascular tissue and parenchyma. These wounds may be due to 
an active agent, such as blows or falls ; or to a passive cause, such 
as excessive swelling brought on by a general disease. While such 
a great enlargement is rare, nevertheless minor but noteworthy 
degrees are very common ; for since the organ acts as a sort of 
filter, it is commonly affected by the acute infectious diseases, 
chronic and wasting diseases. In this manner a sufficient en- 
largement may occur to make the danger of wounds possible. 



CHAPTER X 
DISEASES OF THE LARGE INTESTINE 

Acute Ileo-colitis 

The inflammations of the colon, the ileum, and the large intes- 
tine in general have a very unsatisfactory classification and 




Fig. 18. — Normal Intestine. X 70. 

nomenclature. This is due to our imperfect knowledge of the 
micro-organic life and the chemical changes in the faeces. In for- 
mer years, when we were less conscious of our ignorance, no at- 
tempt was made to arrange or classify the group of symptoms 
which are characteristic of intestinal organic lesions. With the 
investigations of men like Escherich and Booker, a knowledge of 
our limitations came into active existence ; and one of the first 
fruits of this dissatisfaction was the abolition of the term dysen- 

153 



M 



154 THE MEDICAL DISEASES OF CHILDHOOD 

tery. The name colitis and ileocolitis were elected to fill the 
vacant place, but not as a necessarily permanent term. The usual 
classification that is applied to the inflammations of mucous mem- 
branes in general was affixed to the disorders in question. Im- 
mediately practitioners began to find fault with the difficulty in 
assigning the clinical appearances to the pathological changes, as 
well as with the provisional nature of the statements concerning 
those changes. Even now the dissatisfaction continues ; practi- 
cally the distinction between colitis and ileo-colitis is lost, and the 




Fig. 19. — Catarrhal Enteritis. X 70. 

various forms of the inflammation have come to have an academic 
rather than a working interest. 

Causes. — Ileo-colitis is generally preceded by some form of 
infection enteritis. The denuded epithelium gives an opening to 
the attacks of bacteria and infusoria, of whose exact character and 
life history we are poorly informed. Among them various sorts 
of streptococci are thought to hold a prominent place. Continued 
habits of bad feeding are likewise liable to bring about the same 
result by producing an irritation of the mucous membrane and 
thus making a good culture ground for micro-organic life. High 
temperature and great humidity also seem capable of sufficiently 



DISEASES OF THE LARGE IXTESTINE 



155 



depressing the vital tone so that resistance to disease is much less- 
ened. The sum of our knowledge is yet merely general ; and the 
field for research remains very wide. 

Lesions. — The pathological changes are commonly grouped in 
the colon and part of the ileum ; these limits are not absolutely 
fixed, and may be extended either as far as the stomach in one 
direction or the rectum in the other. The degree of inflammation 
is likewise not constant, varying in different parts of the same in- 




Fig. 20. — Ulcer of Ileum, x 50. 

testine. In many post-mortem examinations this exaggeration of 
local change of tissues is emphasized by the rapid disintegration 
that follows death. 

In the catarrhal inflammation, the mucous membrane is 
swollen and congested, producing an unduly large amount of mu- 
cus and serum. The capillaries maybe so much swollen and con- 
gested, so friable, that insignificant agents produce haemorrhages 
of greater or less intensity. The epithelium is denuded, in some 
places for large areas. In these areas more than elsewhere the 
inflammation extends into the superficial structures through the 
mucosa, even into the connective tissue. The greatest amount of 
inflammation carries the greatest quantity of pus cells. Outside 



I^B^ 



156 



THE MEDICAL DISEASES OF CHILDHOOD 



of these lesions there are swelling and congestion of Peyer's 
patches, the solitary and agminated glands and the minute glan- 
dular structure throughout the gut and mesentery. 

Where this inflammatory process is severe, the epithelium 
over the follicles breaks down, followed by the destruction of the 
follicular tissue. Thus, small ulcers are formed which, when 
in close juxtaposition, are apt to merge and make large ulcers 
with undermined edges. This constitutes the so-called ulcerative 
variety. 




Fig. 21. — Ulcerative Colitis. X 30. 

In the croupous or membranous variety, we have the severest 
form of ileo-colitis. Here the congestion is very intense, the 
swelling is so marked that the bowel is stiff and hard, and the 
infiltration is so great that the surface is irregular and even fis- 
sured. A pseudo-membrane, composed of fibrin, blood cells, and 
bacteria, covers scattered portions of the gut. Although the 
principal seat of this formation is in the colon and the adjacent 
portion of the ileum, nevertheless other parts of the large intes- 
tine from the sigmoid flexure down through the rectum may be 
similarly invaded. Not only is the mucosa inflamed, but the 
connective tissue also may be involved. Even the muscular and 
peritoneal coats may be infiltrated with fibrin and pus. The 



DISEASES OF THE LARGE INTESTINE 



157 



process very rarely extends to the peritonaeum except in small 
areas of plastic inflammation which give scarcely any additional 
symptoms. On account of the malignant intensity of the worst 
attacks, one or more of the layers of the intestine may lose suffi- 
cient vitality to insure breaking down of the wall and formation 
of an ulcer. This, however, is not often seen. 

Symptoms. — The course of the sickness soon shows that the 
lesions do not explain the severe symptoms, and that fully to 
understand them one must place most stress upon the toxines — 




Fig. 22. — Croupous or Membranous Ileo-Colitis. X 30. 

whatever they may be — that are elaborated by the micro-organ- 
isms in the intestines. Either there may have been a previous 
gastro-enteritis or the ileo-colitis may begin as a primary disease. 
At all events one sees at first disturbances of the stomach and 
intestines with a rise of temperature to 39.5° or 40° C. (103° 
or 104° F.). The fever, excepting in very mild cases, remains 
fairly high, with intervals of exacerbation and remission, until 
the end of the sickness sets in. From the first the child is in 
much pain, which he shows by continual restlessness and crying. 
At first the movements are characteristic of diarrhoea, being yellow, 
brown, and green ; they are partially formed, and have an mi- 



ni 



H 



« 



. 



158 



THE MEDICAL DISEASES OF CHILDHOOD 



pleasant odor. After the intestinal track has been emptied, the 
movements are very frequent, small, and composed largely of mu- 
cus and small amounts of blood in the form of streaks or little 
masses. Not often does one find the blood fluid and in consider- 
able quantity. At times there may be attacks of vomiting, espe- 
cially if the food is not very easily digested. Commonly the 
urine is diminished in quantity and holds in solution a small 
amount of albumin. The child is plainly prostrated, the tongue 
is heavily coated, the loss of strength and flesh is very apparent. 
The abdomen at first has no remarkable signs, but as the disease 




Fig. 23. — Membranous or Croupous Colitis. X 70. 

wears on, it may become enlarged, tympanitic, and tender. If 
the patient is very sensitive, he may suffer from delirium or even 
convulsions. This is the case in children of all ages, but infants 
have a marked tendency towards prostration and convulsions. 
They seem peculiarly unable to withstand the poisons of the 
disease and show this disposition at an early stage of the illness. 
If the inflammation spreads to the rectum, the suffering before 
and after defaecation is extreme, calling forth shrill cries of pain. 
At the same time there will be much straining and occasionally 
a prolapse of the rectum, usually not more than from 3 to 5 cm. 



DISEASES OF THE LARGE IXTESTIXE 159 

in extent. The prolapsed gut is always much congested and 
swollen. The skin around the anus and along the buttocks is 
commonly excoriated on account of the irritating nature of 
the movements. 

As the child recovers, the temperature subsides, the blood 
leaves the stools, which gradually become feecal. A rapid return 
to health is not to be expected. 

The variety of follicular ulceration is not by any means easy 
to diagnosticate. It is principally known by the small amount 
of vomiting, the small quantity of blood, the large masses of mu- 
cus, the protracted course, and the fact of previous attacks of 
acute or subacute infectious gastro-enteritis. The movements 
are apt to be less numerous, less watery, and to have more color. 
The emaciation is marked, and the physical depression is extreme. 

The croupous or membranous variety is exceedingly severe 
and generally fatal. During its course it is at times apt to be 
confounded with the severe cases of catarrhal ileo-colitis. It is 
distinguished by the general intensity of its symptoms, its high 
fever, delirium, the large quantity of blood in its stools, the more 
common invasion of the lower rectum, and the consequently in- 
creased tenesmus and straining. The principal diagnostic point 
is the presence of pieces of membrane in the stools or on the 
surface of a prolapsed rectum. 

Treatment. — A safe rule to follow is to give small doses of 
calomel (0.006 gm. — -^ gr. — every fifteen minutes for ten doses) 
followed by a dose of castor oil. All milk should be rigorously 
excluded from the diet, which is to be composed of albumin water, 
home-made beef extracts, and meat broths. The patient generally 
suffers from thirst, and will get some relief from drinking cool, 
sterile water. The fever may be combated by hot or cool packs, 
by sponging with alcohol and water, or by the graduated cool 
bath. This last must be given with caution when the child is 
prostrated. In all cases where it is prescribed, active friction of 
the surface should accompany it ; and when the child is placed 
in his crib, the nurse should see that his extremities are comfort- 
ably warm. The regular bathing must, under all circumstances, 
be continued every day. Also, an invariable rule is to keep all 
utensils and clothing about the child clean and sterile. 

One of the most useful measures at our command is irrigation 
of the lower intestine. This, to be efficacious, must be sufficiently 



160 THE MEDICAL DISEASES OF CHILDHOOD 

copious and frequent. The child should be so placed that the 
buttocks are somewhat higher than the shoulders. By means of 
a well-greased rectal tube of small calibre from 2 to 4 litres (1 to 
2 gallons) of warm normal salt solution — salt, 4 gm. (1 dr.) to 
sterilized water (1 pt.) — may be thrown into the bowel. This 
may be used two, three, or four times a day as the condition of the 
child demands. When much blood is in the stools, relief may be 
obtained by enemata of ice water. A wise use of these various 
irrigations will relieve much of the tenesmus, and thus do away 
with the necessity of giving opium by mouth, hypodermatic injec- 
tion, or enema. Nevertheless, in spite of all efforts to the contrary, 
it may occasionally be necessary to give this drug. If so, it is best, 
in infants, to give the deodorated tincture in a starch enema or, in 
older children, a minute dose of morphine, hypodermatically. 
This step, however, is not commonly necessary. 

Another drug that is of some use is the subgallate of bismuth, 
according to the following prescription : — 



B Bismuthi Subgallat. . . . 


IVliSTKLU. 

5.0 


3i gr. xv 


Mucilag. Acacise. 


10.0 


3ij pss 


Glycerini 


12.0 


3iij 


Aquam ad 


60.0 


3ij 


TT^. S. One teaspoonful every two hours. 







This drug, as well as all the bismuth preparations, must be given 
in large doses to produce a definite result. Therefore in older 
children the dose may easily be doubled. One need have no fear 
of toxic effects, since the drug is not absorbed but rather is 
intended to coat the mucous membrane of the gut. On the other 
hand, the use of astringent enemata, which were formerly much 
employed, is of doubtful value. They are liable to do harm, and 
generally one can do without them. In the few cases where they 
may be thought to be indicated, their strength should not be great. 

In all these cases an important part of the treatment is to keep 
up the strength by stimulants. Good whiskey or brandy in small 
and frequent doses and well diluted may be used ; and when pros- 
tration is present, a wise and liberal use of nux vomica may be 
very valuable. 

As convalescence sets in, tonics containing nux vomica or 
strychnine and an organic preparation of iron may be advanta- 



DISEASES OF THE LARGE INTESTINE 161 

geously prescribed. The return to ordinary diet should be gradual 
and conservative ; and if the disease shows signs of breaking out 
afresh, the restricted method of feeding must directly be resumed. 
The patient from the earliest permissible date in the sickness 
should be kept in the air as much as possible. In warm weather 
total residence in the open is highly advisable ; and at all events 
city children should with the least delay be removed to the 
country. 

Differential Diagnosis. — Ileo-colitis is to be distinguished from 
infectious gastro-enteritis by its frequent small stools which con- 
tain much mucus, blood, or membrane, by its continued high 
temperature and its smaller amount of vomiting. From intussus- 
ception it can easily be marked off, as it lacks the normal tem- 
perature and small, mucous stools followed by constipation, 
gas-production, tumor, faecal vomiting, and collapse that charac- 
terize that accident. From typhoid fever it may be diagnosticated 
by the fever's characteristic temperature, enlargement of the spleen, 
eruption, tympanites, and greater rarity of occurrence in infants ; 
the absence of Widal's reaction will confirm the opinion. 

Prognosis. — In the mild forms and in children who have been 
fairly well cared for, the outlook is on the whole good. With the 
severer forms, in very young children, in those who have been 
badly fed, badly cared for, who have been shut up in tenement 
houses or in institutions, the prognosis is bad. The personal 
equation is an important factor in the outcome of the disease. 
Also those cases where in the course of the disease the patient 
contracts broncho-pneumonia have a serious complication to face. 

Chronic Ileo-colitis 

The chronic form of ileo-colitis occurs, as a rule, as the sequel 
of an acute attack, although a few cases have, in the beginning, 
the slow and gradual characteristics of chronicity. Most of these 
acute cases are of the mild or medium catarrhal variety, while a 
few survive a moderate degree of follicular ulceration. Thus the 
severest examples of both varieties as well as almost all of the 
croupous are excluded by death. 

Lesions. — As a rule only a part of the colon and the large 
intestine is involved, and in the part affected the changes rarely 
have the same degree of intensity throughout. Instead of a tern- 



162 THE MEDICAL DISEASES OF CHILDHOOD 

porary inflammatory change, as in the acnte form, there is a defi- 
nite alteration in the minnte structure of the intestine. Between 
the tubules in the large intestine, and to a less extent between the 
villi in the small intestine, there is a connective tissue which in- 
creases the thickness of the whole glandular coat. This thicken- 
ing may be communicated to the muscular and peritoneal layers. 
In some places the deposition of connective tissue is so marked 
as to crush out and atrophy the tubular formation, and then lead 
to a wasting of the whole stratum. Where the atrophy of the 
glandular tissue is rapid, the surface may be so weakened that it 




Fig. 24. — Chronic Catarrhal Colitis. X 50. 

breaks down into ulcers whose size and shape depend upon the 
extent and position of the region involved. In the same way, the 
solitary follicles may be attacked, may break down, and likewise 
form ulcers. These various ulcer-formations may gradually heal, 
be replaced by connective tissue, or linger in a granulating condi- 
tion. Some rare cases of polypoid and cyst-like growth have 
been reported as resulting from obliteration of the mouths of 
glands. 

Symptoms. — This chronic form, in contradistinction from the 
acute, does not have many characteristics of a septic infection. 



DISEASES OF THE LARGE IXTESTIXE 163 

On the other hand, the main symptoms arise from the great physi- 
cal depression, the alteration in the glandular structure of the in- 
testine, and the fermentation and putrefaction of food. The course 
of the disease, if these factors are kept in mind, is fairly easy to 
understand ; especially if one recognizes the great facility with 
which the exhausted economy succumbs to new forms of disease 
or acute exacerbations of the old complaint. 

When the acute symptoms subside, the child does not materi- 
ally improve. The stools are less in number, but are green, or 
greenish brown, or brown, and usually have a foul odor of decom- 
position. Although the child's appetite may be fairly good, never- 
theless he gains almost nothing in weight, and often progressively 
loses. As this process goes on, the child may seem starved and 
wasted, the abdomen may be puffed out, the face and body look re- 
pulsively distorted and even deformed ; the fontanelle may be de- 
pressed, the pulse may be weak, thin, and irregular. Various forms 
of stomatitis, of diseases of the skin and scalp may appear ; and in- 
flammation of the abdominal and thoracic viscera may crop out at 
any time. Other signs of weakness and malnutrition are the lia- 
bility to subnormal temperature, prolapse of the rectum, and ner- 
vous disorders, such as opisthotonos or convulsions. These cases 
are very trying to both physician and parents on account of their 
chronic course, their restlessness, their irritable crying during day 
and night, and the difficulty which they experience in responding 
to treatment for anaemia and malnutrition. Here and there a 
patient recovers or may temporarily improve. But as a rule one 
must expect a succession of changes and secondary diseases which 
tax the child's vitality and the physician's resources to the utmost. 

Treatment. — In this disease, as in the acute form, the general 
management of the case is very important, for there is no specific 
drug to use. The rules of hygiene and sanitation should be rig- 
idly enforced ; the child's baths, exercise, and clothing should be 
carefully supervised. City children should, if possible, be sent to 
the country, or at all events should be kept as much as possible in 
the air. The diet will demand an important share in the treat- 
ment. Fats should be excluded, starches altered by diastase, and 
sugars diminished. Milk, with a small part of its cream retained, 
may often be usefully employed. But the main reliance will have 
to be put upon meat foods. Meat extracts and meat soups are usu- 
ally well borne, and the older patients seem to derive benefit from 



164 THE MEDICAL DISEASES OF CHILDHOOD 

scraped beef, broiled steak, and broiled lamb chops -finely divided 
and very thoroughly chewed. As a rule, the case should be fairly 
well advanced before vegetables may be safely given. 

The medicinal treatment is apt to be unsatisfactory. Symp- 
toms will have to be controlled as they arise ; stimulants, such as 
good whiskey, brandy, o? fine old wines that have a good bouquet, 
will be needed. Nux vomica or strychnine will often do good ser- 
vice, arid when convalescence begins an organic preparation of iron 
may be prescribed. Still later the compound syrup of hypophos- 
phites may be called into play. A measure that will often give 
fairly satisfactory results is irrigation of the large intestine with 
cold water. The frequency of its application will depend upon 
individual circumstances ; in the ordinary cases once a day will 
be enough. All in all, the treatment of chronic ileo-colitis must 
be regulated by the circumstances and environment of each par- 
ticular case and the ingenuity and resourcefulness of the physician. 

Differential Diagnosis. — The main possibility of confusion lies 
in the division between this disease and tuberculosis. Outside of 
the low and irregular fever which characterizes the latter com- 
plaint, the general course of the two sicknesses will gradually 
clear up the question. Most of all, the history of the sickness 
and the peculiar character of the stools will be diagnostic. In 
addition the involvement of various organs in tuberculosis, with 
the inevitable train of additional symptoms, will make the situa- 
tion easily understood. 

Prognosis. — This depends upon the severity of the acute 
attack, the strength of the patient, and the possibility of em- 
ploying every therapeutic measure. On the whole, the outlook in 
infants is not especially encouraging. In older children it is 
somewhat better because they have greater vitality in withstand- 
ing the inroads of the disease. 

Ileo-colitis due to Amcebic Infection 

A rare form of ileo-colitis, as far as its occurrence in temperate 
climates is concerned, is caused by amoeba coli. Generally it is 
imported from tropical countries, where it flourishes vigorously. 

Lesions. — The pathological changes consist mostly in ulcers 
of various shapes and sizes, some of which have undermined and 
others smooth edges. The number of them is variable, but the 
usual experience shows it to be large. There is a surrounding 



DISEASES OF THE LARGE INTESTINE 



165 



zone of congestion and inflammation, with a central area of 
necrotic tissue. In this tissue and the adjacent region amoeba 
coli may be found, as well as in the blood-vessels. Thence it 
works its way to different organs, especially the liver, from which 
it may spread, by the breaking of an abscess, to the lung. In 
these viscera the pathological changes are the same as what one 
finds in the intestines. 




Fig. 25. — Amoebic Ulcer of Colon, x 30. 

Symptoms. — The only respects in which the symptoms differ 
from those of the catarrhal form of ileo-colitis are the low fever 
or normal temperature, the slow and remittent course of the 
disease, and the presence of a?ncebos in the stools. 

Treatment. — The treatment is practically the same as in the 
catarrhal disorder. Various practitioners recommend rectal injec- 
tions of quinine in solutions of 1-5000 to 1-1000. Especial stress 
is to be laid upon the necessity of liberal stimulation. Even then 
the patient will become and remain for a long time much 
emaciated. 

Prognosis. — The outlook is not good, the patient sometimes 
succumbing to mere exhaustion, even although the characteristic 
movements have passed away. Even under favorable circum- 
stances the disease lasts for weeks. 



166 THE MEDICAL DISEASES OF CHILDHOOD 

Infectious Derangements of the Intestines 

The intestines of a new-born child are practically sterile ; 
within a few days, however, the fseces begin to show the usual 
bacteria, although the quantity is smaller than later on in life. 
While the child is kept at the breast the intestinal micro-organisms, 
as a rule, do not become pathogenic. Nevertheless, one must keep in 
mind that even breast milk is not always absolutely sterile ; and, 
in addition, there is always the possibility of communicating infec- 
tion through the persons, utensils, or toys about the child. In such 
ways even breast-fed infants become infected by micro-organisms 
whose toxines may produce various disturbances of the intestines. 
The most common cases occur in hand-fed babies whose food is 
contaminated by pathogenic germs. Such children are often, 
previous to the invasion, in poor general health. Their food has 
not been carefully regulated in quality and quantity, and com- 
monly the whole ordering of their attendance has been faulty. 
Their poor nutrition easily lays them open to attacks of sickness, 
so that when their food is impure they easily become poisoned. 

That these cases should be looked upon as illustrations of pois- 
oning there is little doubt. The efforts of the economy to free it- 
self of offending material by means of prolonged, violent diarrhoea 
and vomiting, the prostration which follows them, and the lack of 
organic pathological lesions make a picture of toxicity. The mere 
fact that we have as yet been unable to isolate and describe all 
the various bacteria that occur in the diarrhoea! complaints does 
not at all militate against this conclusion. For these micro- 
organisms are so numerous that their very plenitude forces the 
belief in a common condition in which one germ may exist as well 
as another ; and it is so difficult to separate the products of one 
from those of another that any attempt at finding the particular 
bacillus to bear the burden of responsibility is at present almost 
certainly bound to fail. For this reason comparatively little has 
been done in tabulating and describing the life histories of these 
organisms, or in producing a useful antitoxic serum. 

Lesions. — The pathological changes vary with the severity of 
the infection, the patient's power of resistance, and the length of 
time during which the disease has continued. Primarily but little 
impression is made upon the gut ; but when a congestion or irrita- 
tion of the mucous membrane exists antecedently, or the patient's 



DISEASES OF THE LARGE INTESTINE 



167 



general condition is poor, the further excitation of acid fermenta- 
tion and albuminous putrefaction may cause various degrees of 
inflammation and molecular degeneration. These effects com- 
monly start in the small intestine ; thence they may spread to the 
large intestine, and also to the stomach. What effect the absorp- 
tion of products of decomposition causes is, on account of the 
many forms and the varying degrees of intensity, almost impossible 
to say. 



PUL. 


RES P. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


'•' 


170 


70 


FAH. 
108 


CEN. 
42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


41.1 
































140 


55 


105 


40.5 






X 


























130 


50 


104 


40.0 
































120 


45 


103 


39.4 
































110 


40 


102 


38.8 








\ 
\ \ 
\ \ 
























100 


35 


101 


38.3 


/ / 
/ / 

1 / 


V 




\ 
\ 

\ 


V\ 




,_/ 


\ 
















90 


30 


100 


37.7 


/ / 
/ / 
/ / 
// 














\ 

\ 
\ 
















80 


25 


99 


37.2 


/ 
/ 

I 


/\ 




\ 








\ 

u- 
















70 


20 


98.6 


37.0 


/> 


t* 




fc v 


\ 






















98 


36.6 


/ 








\ 


•*. 




















60 


15 


97 


36.1 







































































PULSE, RESPIRATION AND TEMPERATURE CHART OF INTESTINAL AUTO-INTOXICATION. 

X = CALOMEL PULSE._______ - _. RESPIRATION _ . ^—-^— TCMPCPATiioe 

AGE, 4 YEARS. 

Fig. 26. 



Symptoms. — The symptoms are best interpreted if one regards 
them as the signs of irritant poisoning. Usually the onset is rapid 
and the child immediately begins to fail. The cases of gradual 
invasion are apt to be those which might be classified as gastritis 
or enteritis ; upon these an infection is easily grafted. Diarrhoea 



Mn 



168 THE MEDICAL DISEASES OF CHILDHOOD 

sets in rapidly, and in most cases is exhausting. This is evident 
from the general condition of the child : he loses weight rapidly, 
the skin hangs loosely where a day or two before it was well 
filled out ; the eyes are heavy and sunken, the complexion is dull 
and yellow, the face becomes wrinkled and old-looking. At first 
the movements are solid or semi-solid, but as the sickness pro- 
gresses they become more and more fluid, until they are merely 
serous. Their number varies, in some cases being five or six per 
day, in others one or more per hour. The color in the beginning 
is yellow, then greenish yellow, and finally green. There is a 
mawkish odor to the faeces that at times may be differentiated 
from the sour smell of acid fermentation or the putrid smell of 
albuminous decomposition. 

The child is constantly in pain and shows it by continuous 
crying until he is exhausted. As his strength fails, his former 
shrieks are replaced by short and irritating moans. If his condi- 
tion becomes more serious, the eyes become dull, the nostrils and 
lips retract, and the fontaaelle becomes sunken. 

The temperature is apt to be elevated, especially in infants* 
ranging from 38° to 40° C. (100.5° to 104° F.) This statement 
is merely approximate, for there are so many degrees of intoxi- 
cation, and the septic agents are evidently so various, that the 
widest limits of temperature are possible. Even with considerable 
fever the surface of the body may seem cool and clammy. 

In children who have passed the age of infancy, the disorder is 
apt to assume a less violent form ; and the depression which it pro- 
duces is neither so alarming nor so dangerous. At the beginning, 
if there is a gastric irritation, there will be some vomiting. But 
this symptom is not necessarily a constituent factor in the picture. 
There will be pain, which is sometimes referred to a definite area 
in the abdomen and sometimes to the general region of the belly. 
At the outset of the disease there will occasionally be one or two 
movements followed by diarrhoea, but more frequently diarrhoea 
will set in immediately. The stools are light-colored, sometimes 
stained with green ; but a uniform green hue is not so common 
as in infants. The appetite will be poor, thirst marked, the 
temperature will have a mounting curve, and the urine will be 
decreased in quantity and high in color. Relief of these symptoms 
will follow proper treatment much more readily than in younger 
children. 



DISEASES OF THE LARGE INTESTINE 169 

Treatment. — The first order should be to stop all food. Then 
the stomach and lower intestine should be cleansed by lavage and 
irrigation. This may be followed by small doses of calomel (0.006 
gm. — y 1 ^ gr.) every quarter-hour until 0.06 gm. (1 gr.) has been 
given. A saline cathartic may then be gh~en to complete the 
cleansing and prevent the storing up of calomel. If the diarrhoea 
arid vomiting are thus controlled, they may be followed bv large 
doses of the subgallate of bismuth for about two days in order 
still further to protect and soothe the irritated mucous membrane. 
But if these symptoms continue, the main reliance must be put 
upon lavage and irrigation, especially the latter. Attempts to 
sterilize the gastro-intestinal track by means of antiseptic drugs 
is a waste of time and opportunity. 

No food need be given for the first twelve hours. By that 
time the stomach ought to be fairly quiet, so that the administra- 
tion of small quantities of nourishment may be resumed. For 
this purpose one may use albumin water or beef extract. At first 
they should be given by the teaspoonful until one is certain that 
the stomach can retain them : then the quantity may gradually 
be increased. Xo milk should be given until the patient, if he is 
an infant, is out of all danger. An older child need not be treated 
so rigidly : but even with him carefulness is highly desirable. And 
if he refuses albumin water and beef extract, the milk which is 
substituted must be well diluted. 

If the temperature is high, it may be safely reduced by means 
of sponging with cool water and alcohol, the graduated bath or 
cool packs. These measures have the additional value of refresh- 
ing the flagging vitality of the child. At times, still stronger 
remedies are called for ; in fact, a wise stimulation is always to be 
kept in mind. For this purpose hypodermatic injections of 
strychnine do the work most satisfactorily. 

The patient should be kept in the air as much as possible, and 
a trip to the country, seashore, or mountains is of much impor- 
tance. After convalescence has set in. tonics, in the form of mix 
vomica or strychnine, combined with small doses of the organic 
preparations of iron, may be given until the child seems in 
flourishing health. The return to the ordinary diet must be made 
slowly and by conservative gradations. 

Differential Diagnosis. — The main error that one is apt to fall 
into is mistaking the diarrhoea, or diarrhoea and vomiting, that 



■m 



170 THE MEDICAL DISEASES OF CHILDHOOD 

occur in the course of the acute infectious diseases, especially in 
the summer, for these derangements. The former disorders are 
not so violent nor so prolonged, the movements usually do not 
have the intensely green color that we are familiar with in infec- 
tious intestinal derangement, and in addition the fact of their oc- 
currence in the course of the acute infectious diseases makes the 
likelihood of their being more than a passing complication very 
small. 

Prognosis. — If these cases are treated promptly and vigor- 
ously, the outlook is good. Half-hearted measures, either in 
cleansing the gastro-intestinal track, or in the restriction of food, 
is as dangerous as the disease itself. As the disease may be easily 
communicated by contact, it is highly desirable that the child's 
napkins, clothes, and bed linen, as well as the hands and clothing 
of the nurse, be thoroughly disinfected as often as possible or 
convenient. 

Subacute Intestinal Infection 

It is difficult to make any serological distinction between the 
acute and subacute forms of intestinal infection. So much remains 
to be found out concerning the natural history of intestinal germ- 
life, that one is not justified in trying to assign responsibility to 
specific bacteria. One may say, in short, that when the tempera- 
ture of the air is 15.5° C. (60° F.) or more, the many micro-organ- 
isms that may infest a child's food begin to have the proper 
condition for existence. A condition of malnutrition, and espe- 
cially a disordered digestion in the stomach or intestines, give the 
opportunity for them to spring into activity. Whether the dif- 
ference in the course of the disease from that of the acute form is 
one of quantity or quality, is a matter that can, with our present 
knowledge, be discussed indefinitely without necessarily coming 
to a satisfactory conclusion ; for the course and symptoms of 
subacute intestinal infection vary widely in different cases and 
thus give an opportunity for much divergence of opinion. 

Lesions. — The pathological changes are not confined to one 
separate part of the intestine. As a rule, they begin in the small 
intestine, whence they may extend in either or both directions. In 
some cases they are surprisingly small in extent and severity. In 
others they include swelling and congestion of the mucous mem- 
brane, exfoliation of epithelium, occasional formation of superficial 



DISEASES OF THE LARGE INTESTINE 171 

ulcers, and the swelling and congestion of the associated glandular 
structures. 

Symptoms. — The disease may, and often does, begin in a 
gradual fashion. Usually, there is a history of intestinal dis- 
order. The child is fretful, peevish, and shows a loss of flesh and 
strength. The stools begin to increase in number and change in 
quality. The food may be seen in them in undigested particles, 
and small masses of casein and drops of fat may easily be distin- 
guished. At times, these movements may have a disagreeable 
odor, but it is not so penetrating nor persistent as in chronic func- 
tional derangement of the intestines. The stools may vary in 
number, gradually growing greater from the beginning. Their 
hue ma}^ be various, either yellow, brown, or green, or a mixture 
of all three. Especially after the beginning of the disease there 
may be considerable amounts of mucus in the stools ; but this is 
apt to vary from day to day. Associated with these unnatural 
movements is a production of gas, which, when its amount is ap- 
preciably large, causes pain and restlessness. The putrefactive 
processes, which are at the foundation of gas-formation, are 
capable of setting up various forms of toxicity that have a very 
important bearing upon the course and outcome of the disease. 

Although the attack may begin with some vomiting and there 
may be occasional signs of gastric irritability, nevertheless, on the 
whole, the stomach is fairly free from any marked extension of the 
disease in the intestines. A broad statement of the case would 
say that the disease is located in the intestinal track in and below 
the lower part of the ileum, and that practically all absorption of 
toxic matter takes place in these portions of the gut. Whatever 
serious organic changes may take place arise from this cause. 

The temperature is variable, rising with any exacerbative in- 
fluence and dropping when such influence is eliminated. When 
the temperature is high, the tongue is apt to be more coated than 
at other times. The respiration and pulse have a tendency to be 
small, thin and weak. 

The possible complications are many and depend for the most 
part upon the child's debilitated condition. There is a marked 
liability to skin diseases, especially erythematous inflammations 
about the buttocks and eczema of the face and head. Or there 
may be a local or general adenitis. In other cases there may be 
an oedema of the feet and legs, or a troublesome irruption of 



■i 



172 THE MEDICAL DISEASES OF CHILDHOOD 

stomatitis, or an invasion of tuberculosis or hypostatic pneumo- 
nia. Most of all, one must keep in mind that children who are 
suffering from subacute intestinal infection have lost much of 
their original resistance to disease and therefore easily contract 
all manner of germ-diseases and, in a lesser degree, diathetic 
diseases. 

Treatment. — The preventive treatment is of the greatest pos- 
sible importance. A child who is fed on breast-milk of good 
quality, who enjoys the advantages of rigid cleanliness, of exercise 
in the air, and of hygienic domestic surroundings, will not, accord- 
ing to ordinary experience, run much danger of intestinal infec- 
tion. It is of real importance that a family physician should 
explain to the mother the meaning of infection in general and the 
ease with which children contract infectious and fermentative dis- 
orders of the gastro-intestinal track. She must understand the 
responsibility that rests upon the child's unboiled napkins and the 
nurse's infected hand, upon utensils that are not absolutely sterile 
and toys that are filthy. 

As soon as the attack begins, the stomach and intestines should 
be emptied by repeated fractional doses of calomel followed by 
castor oil, or, in larger children, citrate of magnesia. After this 
the lower intestine should be thoroughly irrigated with a sterile 
normal salt solution, as described in the treatment of acute 
intestinal infection. This washing may be practised every day 
until the movements are fairly normal. In some cases, that are 
marked by much tenesmus, one or two small doses of the deodor- 
ated tincture of opium may be needed to give rest and quiet. In 
more instances a liberal use of the subgallate of bismuth every 
hour for a day or two will bring about the same result. In all of 
these children the strength will in part be maintained and recovery 
facilitated by the liberal use of tonics and stimulants. For this 
purpose I have used mix vomica or strychnine with considerable 
satisfaction, sometimes combining it with an organic preparation 
of iron. Occasionally one may use, to bridge over a crucial 
period of depression, small and repeated doses of good whiskey 
or brandy. Whenever the condition of the child permits, and the 
weather is bearable, he should be taken into the air and kept there 
as long as possible. Residence in the country or at the seashore 
is better than in the city, and cool, airy rooms have a distinct 
remedial advantage over hot and stuffy apartments. In short, 



DISEASES OF THE LARGE INTESTINE 173 

every aid in the way of sanitary and hygienic regulation has a real 
value in the effort to regain health. 

From the very first, all milk must be excluded from the dietary. 
This rule is rigid and no advantage can be obtained by trying to 
modify it. The food may be made up of albumin water, of home- 
made beef extract and some barley water. These can easily, by 
the use of judgment and tact, be so manipulated as to satisfy the 
child's hunger and the parents' anxiety. When convalescence 
has set in, much good may be obtained from the use of iron, the 
compound syrup of hypophosphites and occasionally from cod- 
liver oil. 

Prognosis. — The question whether these cases will live or die 
depends much upon the degree of wisdom exhibited in the medi- 
cal and general care of the patient. Poverty and ignorance have 
destroyed their thousands. If all circumstances are favorable, a 
large majority recover. The parents must be warned that until 
recovery is fully established there is a constant danger of recru- 
descence. 

Chronic Functional Derangement of the Intestines 

This disorder is in large part the result of ignorance, therefore 
it is commonly seen. The majority of its causes are avoidable, 
but their effects, when once set in motion, are not so easily con- 
trolled. These causes are wrong feeding, too frequent feeding, 
exposure, uncleanliness, repeated attacks of acute derangement 
which have not been carefully treated, and deficient regulation 
and control of the general life of the child. It is not often 
that one sees, in a general and mixed practice, an infant whose 
diet, if artificial, is really well arranged. Especially are parents 
not apt to reckon on the general debility that follows acute gastric 
disorders, the eruptive fevers, and the frequent attacks of bron- 
chitis to which babies are subject. In fact, the subject of infant 
feeding is not, as a rule, handled with sufficient thoroughness and 
seriousness by parents, nor even by many medical men. They 
lose sight of the fact that the milk upon which an infant lives is 
composed of various elements which depend for their digestion 
and assimilation upon diverse secretions, and that a congenital or 
acquired disturbance of equilibrium, as commonly worked out by a 
method of averages, makes the ordinary artificial food undesirable. 



174 THE MEDICAL DISEASES OF CHILDHOOD 

This statement is true of human milk which varies from the 
standard ; and the mere fact that a mother has a plentiful supply 
of milk, or that she may have nursed other children with success, 
does not at all mean that her milk is suited for the patient in 
question. The continued administration of such a diet is one of 
the commonest and least appreciated causes of chronic functional 
derangements in infants. In addition, the deterioration, either 
bacterial or fermentative, of the food-contents of the intestines is 
a fruitful cause of various organic lesions and conditions of low 
intoxication. 

In older children an unregulated and too promiscuous diet 
will accomplish much the same results. Lack of cleanliness has 
its share of importance in the causality, especially in summer, 
when the heat and humidity hasten the decomposition of food and 
make infection easy. 

Lesions. — On examination one may find in the less serious 
cases almost no pathological changes. As the condition becomes 
graver one may see an irritation and swelling of the mucous 
membrane, a congestion of the glands and lymph nodes. Not 
only are the lesions not constant, but also they are not uniform 
in their location. Thus they may start at any part of the small 
or large intestine and thence work their way up or down. 

Symptoms. — From the first the patient begins to show 
malaise or even prostration. The mental depression may be 
noticed before the physical inroads of the disorder are pro- 
nounced. The eyes look heavy, the skin dull, the tongue some- 
what coated. After a short period, the weight of the child begins 
to decrease and finally extreme emaciation may result. Although 
the limbs, neck, and chest may be much wasted, the abdomen is 
often puffed out and distended ; there may be sufficient stretch- 
ing to make the superficial veins unusually visible as thin blue 
lines. For the most part this is caused by the presence of vari- 
ous gases of decomposition which the atonic muscular tissue is 
not able to confine within the ordinary calibre of the intestines. 
Naturally there will be attacks of pain and discharges of gas. 

The movements at the beginning of the attack are disordered, 
periods of diarrhoea following short times of constipation. After 
the disorder is well under way an irregular diarrhoea may be ex- 
pected. As a rule the stools are not profuse, are semi-fluid, and 
are characterized by the presence of varying amounts of undi- 



DISEASES OF THE LARGE INTESTINE 175 

gested food. This last item helps to give the clay or putty color 
that is so often seen. At other times one may notice the shades 
of green that are present as the product of chromogenetic 
bacteria or the unusual excretion of the biliary coloring 
matter, biliverdin. A characteristic feature of the faeces is 
their offensive odor which is so pronounced as to induce some 
observers to call these movements "putrid." During an attack 
of constipation the passage of a large, hard mass of faeces may 
scratch the mucous membrane and bring forth a thread of blood. 
This must not be confused with a possible ulceration of the in- 
testine which usually is indicated by dark, clotted blood in a 
dark, watery movement. 

The child's appetite is poor, and if he is induced to eat, the 
process is apt to be followed by diarrhoeic movements. Tenes- 
mus, accompanied by pain, may characterize this condition. 
Exacerbations, such as these, may elevate the temperature 
slightly ; otherwise it does not run high, and at times of prostra- 
tion it may be subnormal. At such periods the pulse is weak 
and small, the respiration tends to irregularity. The liver, spleen, 
and mesenteric glands do not seem to the touch to be enlarged, 
nor do we find albumin in the urine. 

When convalescence sets in, one notices first of all that the 
mental condition is improved, the restlessness and peevishness 
decrease, and the face loses its drawn and puckered aspect. In 
infants the secretion of tears, which in the height of the sickness 
had been interrupted, is resumed. The body begins slowly to fill 
out and the movements become fewer. For a long time the foul 
odor persists in them and the change of color to the normal is 
gradual. This evolution to health is practically never uninter- 
rupted, even though the treatment and general care be wise. 
The lapses, however, become progressively shorter. It is note- 
worthy that humid and bad weather has an unfavorable effect 
upon these cases, while under favorable meteorological conditions 
they are much more comfortable. 

Treatment. — An important part of the treatment is the gen- 
eral care. The patients, especially infants, must be warmly 
clothed, and especially must the extremities be kept warm. 
Care must be exercised that the child be not chilled during or 
after the daily bath. Cleanliness of the mouth is of especial im- 
portance ; the ventilation of the nursery, the airing of the bed 



176 THE MEDICAL DISEASES OF CHILDHOOD 

linen, and the cleanliness of the clothes must be carefully super- 
vised. All milk must be forbidden and replaced by albumin 
water or beef extract. In older children the diet may be com- 
posed of clear meat soups, soft-boiled or poached eggs, toast, or 
zwieback, scraped beef or lamb, with as small a quantity of 
starchy vegetables as possible. At times wine- whey may be 
useful. 

The medicinal treatment is simple, and on the whole less im- 
portant than the dietetic. The intestinal track may be emptied 
by means of calomel in divided doses, followed by a saline cathar- 
tic, such as the citrate of magnesia. The subgallate of bismuth 
may be used, preferably in large doses (0.3 gm. — gr. v every two 
hours for a child of three years). The bowel may be thoroughly 
irrigated every day with a warm normal saline solution. One of 
the most necessary details to keep in mind is the treatment of the 
mental and physical depression. This can best be done by the 
administration of nux vomica or strychnine ; the latter, adminis- 
tered hypodermatically, is of the greatest value in the collapse 
which sometimes attends this sickness. In some cases, especially 
in older children, small doses of whiskey or brandy diluted may 
be temporarily required. 

When convalescence sets in, these children are often benefited 
by being taken to the country, where they should be kept until 
recovery is complete. 

Prognosis. — The outlook is fairly good. Nevertheless the 
parents must be informed that the sickness is apt to be tedious 
and convalescence prolonged. 



CHAPTER XI 

DISEASES OF THE LARGE INTESTINE {Continued) 
Intussusception 

Causes. — Intussusception, or, as it is sometimes called, invag- 
ination of the intestine, occurs more frequently during infancy 
than at any other period of life. Boys seem to be oftener attacked 
than girls, but the question of sex does not have any influence 
upon the course or mortality of the disease. The origin of the 
condition is hard to locate ; nevertheless one can obtain a logical 
idea of it from experimental research. We know that electrical 
stimulation causes local contraction of a tense, spasmodic nature ; 
when this ends, the portion under it rolls up and over it. In 
the living subject the process probably starts from the irritation 
brought on by improper food. This may happen from either an 
antecedent intestinal derangement or food that is taken in a state 
of health. Thus one can understand that some cases. of severe 
colic, which eventually recover, are really examples of intussus- 
ception that become reduced either spontaneously or by the action 
of sedatives. 

Lesions. — The changes take place, as a rule, in the peristaltic 
line, from above downward; only exceptional cases reverse the 
direction. Usually there is no more than one layer of intestine 
invaginated in another ; nevertheless there are unusual occur- 
rences of a series of two or three invaginations, one inside of the 
other. The condition can be simply and satisfactorily imitated 
with the finger of a glove, and a more elaborate and satisfactory 
counterfeit can be made with one or two metres of bullock's gut. 
It is advisable to make such a reproduction ; for one immediately 
will have a vivid picture of the condition of the three layers, 
the outer and inner of which run in their normal direction, while 
the middle is reversed, its mucous membrane lying in contact with 
that of the outer. The condition may occur in any part of the 
intestine, but the commonest location, occurring in three-fourths 
n 177 



MB 



178 THE MEDICAL DISEASES OF CHILDHOOD 

of all the cases, is where a part of the ileum descends into the 
colon ; the next common in frequency is in the colon, and after 
that come invaginations of the small intestine. 

As a result of the pulling and squeezing on the mesentery as 
well as the gut — which is especially liable to happen in infants — 
congestion, hemorrhage, inflammation, and gangrene may super- 
vene. In fact, it is from one or more of these factors that the 
serious symptoms of great swelling of the invaginated portion, 
adhesions of the layers, and sloughing of the constricted part 
result. With these changes, concomitant lesions of peritonitis 
may supervene. Difficulty in reduction may be increased by 
strain from the mesentery, which changes the right shape of the 
affected part to a concavo-convex outline. 

Symptoms. — If there is no previous disorder of the gastro- 
intestinal track, one ought to have no trouble in diagnosis. Gen- 
erally the onset of paroxysms is sudden and the cries which they 
elicit are piercing and startling. Almost simultaneously the child 
vomits and has one or a few loose movements of the bowels. 
Following these there will be a number of small fluid movements 
consisting of mucus stained more or less copiously with blood. 
The temperature is normal or subnormal, the face during the par- 
oxysms is puckered and anxious, the pulse is feeble and often 
irregular, and a general picture of marked prostration gradually 
unrolls itself. Shortly one may in more than two-thirds of the 
cases feel a tumor in the abdomen, most often on the left side 
in the region of the sigmoid flexure, which increases in size as the 
invaginated portion slips lower and lower toward the anus. The 
abdomen is soft and unstretched until tympanites begins ; as this 
happens, the temperature rises and may remain high; the total 
obstruction is apt to induce stercoraceous vomiting (although this 
is less frequent in children than in adults), the pain becomes 
almost unbearable, and the patient is apt to fall into collapse. 

A minority of the cases, especially recurrences, begin with a 
fairly gradual onset. In a short time, however, they present the 
characteristic picture of the disease. Recurrences are apt to 
occur, especially if after reduction the child is not kept quiet. 
Fairly often an examination through the anus, even if the tumor 
was originally felt high up, will disclose the end of the invagi- 
nated part in the rectum ; and it is not very rare that this part 
may protrude for one or two inches through the anus. In other 



DISEASES OF THE LARGE INTESTIXE 179 

and rare cases, the constricted portion may slough off and be passed 
with a movement. In the subacute and chronic cases, which have 
a slower onset and last for weeks instead of days, shreds of gut 
instead of a section may be passed. The ordinary case lasts from 
a day and a half to a week. 

Treatment. — As soon as the diagnosis is made, all food, 
drinks, and cathartics must be stopped. Opiates should be given 
in large enough doses to keep the patient as quiet as possible. 
Usually I prefer to treat these cases by hypodermatic medication 
and thus avoid any additional strain upon the activity of the 
stomach. As soon as the child is quiet, one must attempt to 
reduce the invagination. One had best begin by using hydro- 
static pressure. For this purpose an ordinary fountain syringe 
may be employed, hung about 150 to 200 ctm. (5 ft. to 6 J ft.) 
above the bed. While the water is passing into the rectum, 
the buttocks should be higher than the shoulders. Some practi- 
tioners prefer the totally inverted position ; but this will be of 
use only in the first stage before the invagination is much swollen. 

Another method consists in the use of air forced high into 
the bowel through a soft rubber catheter by means of a bellows. 
When this is done, one usually anaesthetizes the patient. With 
either treatment, while the intestine is being dilated, the abdomen 
must be rubbed and lightly kneaded. In both injection and 
inflation the manipulations must be practised with great care in 
order to avoid the danger of rupturing the bowel. This acci- 
dent has been reported as happening after the employment of 
unusual and, in some instances, moderate force. The physician 
cannot, therefore, exercise too much caution in these procedures. 

If the attempts at reduction are not successful, a surgeon 
should without delay be called in to open the abdomen. The 
longer this step is put off, the fewer are the chances of recovery. 
It is undoubtedly true that delay is far more dangerous than 
operation, no matter how young the child may be. 

Prognosis. — Delay in diagnosis or treatment usually means 
death. If reduction by hydrostatic pressure or inflation is unsuc- 
cessful, delay in operating is almost always fatal. By promptness 
in measures of relief the mortality can, I believe, be reduced to 
50 per cent or even less. 

Differential Diagnosis. — The only conditions with which one 
can confuse intussusception are gastro-enteritis and ileo-colitis. 



■HH 



180 THE MEDICAL DISEASES OF CHILDHOOD 

In reality there is very little in common between them, and the 
mere mention of the possible confusion ought to be enough to 
obviate the probability of it. The history, peculiar stools, early 
vomiting, and temperature of enteritis and colitis are absent ; and 
unless such a rare event as intussusception complicating an enter- 
itis or colitis occurs, the distinction should be readily made. 
The history, vomiting, headache, coated tongue, and the usual 
pains of gastritis mark off this disease very clearly from intussus- 
ception. The projection of an invagination may be mistaken for 
prolapse of the rectum or even haemorrhoids ; but a fairly careful 
examination will correct the error. The possibility of faecal im- 
paction must also be considered. This occurs in the large intes- 
tine, in the caecal or sigmoid region. There is a history of 
gradually increasing incompetence of the bowel due to over-dis- 
tention and the accumulation of faeces. The attack is not acute ; 
there may be a swelling which has a large and not clearly defined 
shape, and when the child is anaesthetized the tumor can be clearly 
indented by the operator's finger. Finally, the principal symp- 
toms which we must expect to find in intussusception are a tumor 
which commonly has a cylindrical form, marked abdominal pains 
that the patient describes as colic, tenesmus which may at first be 
accompanied by a few small and loose movements, but later on by 
the passage of blood-stained mucus. 

Volvulus 

When the mesentery of the bowel is very long, especially of the 
sigmoid flexure of the colon and the nearest portion of the ileum, 
a twisting of the gut upon its axis may occur, which is called 
volvulus. It may be due to a large mass of hardened intestinal 
contents or a great collection of Ascarides lumbricoides, or to 
unknown irritations. The disorder is not by any means a common 
one, especially in children. The symptoms are much the same as 
in intussusception, except that there may be no blood or even 
mucus discharged. Among them will be pain, prostration, a 
slightly elevated or even subnormal temperature. If the twisting 
is in the small intestine, vomiting will set in early and be a promi- 
nent feature of the symptomatology ; if the sigmoid flexure is the 
part involved, the vomiting may not appear until the condition 
is plainly urgent. If one can distinguish Wahl's sign (a well- 



DISEASES OE THE LARGE INTESTINE 181 

defined tympanitic spot at the site of the volvulus), the certainty of 
correct diagnosis is much increased. The treatment consists in 
laparotomy as soon as diagnosis is made. Nothing is gained by 
delay excepting a greater probability of rapid death. A majority 
of the cases, when promptly operated upon, recover. 

Animal Parasites of the Intestines 

The animal parasites which live or breed in the human intes- 
tines belong, for the most part, to the sub-kingdom of worms and 
are divisible into the two classes, platyhelminthes and nemathel- 
minthes. The first are " worms with a flat, elongated body, very 
generally provided with hooks or suckers or both ; they possess 
a cerebral ganglion and, as a rule, are hermaphrodite." The sec- 
ond are " roundworms with a tubular or filiform bod}^, the cuticle 
of which is often ringed ; the head end may be provided with hooks 
or papillae : the sexes are separate." Of the platyhelminthes two 
orders are described: Cestoda (tapeworms) and Trematoda (flukes). 
Of the latter there have been only the fewest instances among 
children. Of these Cobbold reported a case of infection of a large 
distome (D. Crassum) in a child who had resided in China. 
Many species of the platyhelminthes are known to live in the 
human body, but not all are associated with child life. Of these 
latter the commonly known appear in the following table: — 

Platyhelminthes 

Cestoda, 

Family — Taemada 

Taenia nana Taenia flavopuncta 

Taenia echinococcus Taenia solium 

Taenia mediocanellata Taenia cucumerina 
Family — Bothriocephalida 

Bothriocephams latus 

Tapeworms have certain common characteristics : they have 
a long, flat, whitish body, called strobila, composed of many seg- 
ments, or proglottides. This body is surmounted by a minute 
head and neck, termed scolex. Generally there are one or more 
rows of hooklets placed about a central rostellum or beak ; in all 
cases there are two or four suckers or discs which aid in attaching 
the parasite to the intestinal wall of the host. The mode of trans- 



182 THE MEDICAL DISEASES OF CHILDHOOD 

ference and growth is simple. The proglottides, when the eggs 
which they contain are ripe, leave the intestinal canal. These 
eggs, in order to infect another host, must be swallowed. This 
may be done directly if they are expressed by the proglottis ; or in 
other cases the whole segment is swallowed and when the wall is 
digested in the stomach the ova are free. The embryo, after shed- 
ding its outer covering, works its way by means of its six hooklets 
to the maturing place. These hooklets are then shed, and from 
the opposite end of the embryo a scolex begins to grow. In this 
stage the organism is called a cysticercus, on account of which the 
type of organism is called cystici ; another type whose cysticercal 
process is very small is called cistoidei. The echinococcifer are 
characterized by the so-called echinococcus cysts, from the inner 
wall of which secondary cysts or brood capsules bud out. In the 
bothriocephalida3 no cysts are formed ; in these parasites the em- 
bryo enlarges gradually but directly in the intermediate host and 
in such form is taken into the system of the definite host. 

Ordinarily the cysticercus in the muscles, connective tissue, or 
viscera of the intermediate host finds its way into the intestines 
of the final host where it attaches itself and grows into the mature 
worm. 

Tcenia medio canellata (synonyms : T. saginata, T. inermis, 
Taeniarhynchus mediocanellatus) is the commonest tapeworm that 
we find in children. They become infected by eating raw or im- 
perfectly cooked beef which contains the cysticerci. The parasite 
is from four to eight metres long, and has a thousand or more 
proglottides, the largest of which are from fourteen to eighteen 
mm. long and twelve to fourteen broad. The head is very small 
and has four suckers but no rostellum or hooklets. The eggs are 
only 0.03 mm. in diameter and have an embryo with six hooklets. 
The cysticerci may live for years without losing their vitality. 
This parasite is more widely distributed in eastern Europe, Asia, 
and Africa than in western Europe and the United States. The 
affected beef is easily recognized by the presence in it of narrow 
cysts, one ctm. in length. 

About two months are required for the development of the 
cysticercus into the full worm, which may live for many years, the 
exact number not being known. 

Tcenia solium finds its way into the intestine in raw or imper- 
fectly cooked pork which is infected with the cysticerci. It is 



DISEASES OF THE LARGE INTESTINE 183 

found wherever the pig exists, and grows most luxuriantly where 
the animal is poorly cared for. The parasite is characterized by 
having twenty-two to twenty-eight hooklets in a double row about 
the rostellum and by its four suckers. It is from three to three 
and one-half m. in length. The proglottides are considerably 
smaller than those of T. mediocanellata. The embryo has six 
hooklets. 

Tcenia echinococcus is described under the heading of Echino- 
coccus Cysts of the Liver. 

Tcenia nana (Cystoidei) is the smallest tapeworm which occurs 
in human beings. It is from twelve to twenty mm. in length and 
one-half mm. in breadth. It has from twenty-two to twenty-eight 
hooklets about a rostellum and has four suckers. Its embryo has 
six hooklets, and is enclosed in a double shell. It is more apt to 
occur in warm than in temperate or cold climates, and preferably 
in children than in adults. 

Tcenia flavo-punctata is a very rare worm which has been found 
only in children. It gets its name from a yellow spot that occurs 
on the proglottides of the fore part of the worm. The segments 
are triangular or trapezoid in form, and measure three mm. in 
length and four mm. in breadth. The embryo has six hooklets. 

Tcenia madagascariensis has been seen in Asia and Africa. Very 
little is known of it. 

Tcenia cucumerina (synonyms : T. canina, T. elliptica) is said 
to develop in the dog-louse QTrichodectes canis). From the af- 
fected dog or cat it finds its way into the human subject, who 
generally is young. It measures from twelve to thirty -five mm. 
in length and its segments are from one and one-half to two mm. 
in breadth. The head has from forty to sixty hooklets about its 
rostellum as well as four suckers. 

Bothriocephalus latus has some individual characteristics which 
differentiate it sharply from those described above. It grows from 
eight to sixteen m. in length, has from three thousand to four 
thousand proglottides, the middle ones of which measure from 
four to five mm. in length and ten to twelve mm. in breadth. 
Toward both ends the width of the worm decreases markedly, the 
neck especially being very narrow. This worm has no cysticer- 
cus form. The eggs while in water develop six hooklets. They 
must then be swallowed by some animal as yet unrecognized by 
which they are transferred to certain fresh- water fish where they 



184 THE MEDICAL DISEASES OE CHILDHOOD 

may lie free or encysted. When such fish is eaten raw, smoked, 
or partially cooked, the parasite is transferred to the animal eat- 
ing it. 

It is found in Russia, Switzerland, Italy, Japan, Ireland, the 
United States, and other fish-eating countries. The life of the 
worm is long, being sometimes twenty-one years or more. 

Symptoms. — Unless the proglottides are seen in the stools or 
about the patient, it is hard, and in many cases impossible, to di- 
agnose the presence of tapeworms. There may be various nervous 
symptoms, digestive disorders, and possibly anaemia. If the child 
for any reason fasts or confines himself to a milk diet, the symp- 
toms become more marked. The commonly mentioned signs of 
teeth-grinding during sleep, and nose-picking are falsely believed 
to be distinctive of the presence of worms. 

Treatment. — Anthelmintics are best given on an empty stom- 
ach. The usual method is to give a supper of a glass of milk ; in 
the morning a saline cathartic, given on rising, will empty the in- 
testines. After this the oleoresin of male fern may be given in 
capsules. The ordinary dose for children of from eight to ten 
years is 0.75 to 1.0 gm. (gr. xii to xv) in half -hourly doses 
four or at the most five times. This should be followed by a 
brisk dose of castor oil. The child should then lie doAvn until the 
bowels move again. When the worm is expelled, a careful search 
must be made for the head ; for without it one cannot be sure that 
the parasite is entirely removed. 

Other drugs that have been used for this purpose are chloro- 
form, oil of turpentine, pumpkin seeds, kousso, and pomegranate 
root. The last-named drug in an improved form is sold as the 
sulphate of pelletierine ; its use is attended with danger of poison- 
ing and therefore should be omitted in treating children. 

I have used thymol advantageously in these cases ; it may be 
prescribed in emulsion or capsules, in doses of 0.06 gm. (gr. i) 
three or four times a day for a child of five years. 

Nemathelminthes. — Order, Nematoda. This order is composed 
of long, cylindrical animals that inhabit the human intestine. The 
ends of the worm taper off considerably, the tail of the male curv- 
ing so markedly as readily to serve as a means of identification. 
The female is larger than the male. All in all, the sexes are quite 
distinct. 

Family, Ascarida. These worms have long, stout bodies ; the 



DISEASES OF THE LARGE IXTESTIXE 185 

head has one ventral and two dorsal lips. There are two species 
commonly and one rarely seen in children : — 

Ascaris lumbricoides. 
Oxyuris vermicularis. 
Ascaris mystax. 

Ascaris lumbricoides, or roundworm, inhabits the upper part 
of the small intestine. The length of the male is as a rule from 
fifteen to twenty-five ctm. ; that of the female is often twenty 
ctm. more. The breadth of the male is four ctm., that of the 
female is six. The body is firm, of a pinkish color, a glittering 
surface, and has numerous, thin, transverse striations. The ovum 
is spherical in shape, resists heat and cold well, and requires half 
a year or more for its development. The eggs are formed in im- 
mense quantities, although the mature worm is not often found in 
any but very small numbers in one host. The embryo, which may 
exist for years as long as conditions are not too unfavorable, is 
taken into the stomach where its outer envelope is shed. It then 
in a few weeks becomes mature. The worm is found in persons 
of all ages (but most commonly in children), and in all climates. 

Symptoms. — The signs which this worm produces are very 
obscure, and unless the parasite is expelled or the eggs seen in 
the faeces, the diagnosis is never quite certain. It doubtless can 
and does produce disturbances in the gastro-intestinal and ner- 
vous systems, and in the quality of the blood ; but farther than 
this one may not go. Some of its most noteworthy effects are due 
to its ability and disposition to wander into more or less remote 
portions of the body. Thus it has been known to work its way 
into the hepatic and pancreatic ducts, through the intestinal wall 
into the peritonaeum, into the air passages, through the urethra, 
Merckel's diverticulum — in fact all of the thoracic and abdomi- 
nal viscera may be the seat of its migrations and give symptoms 
according to the particular location of the worm and the interfer- 
ence with organic and functional action which its presence creates. 
Another remarkable fact is its disposition to leave the body of the 
host as soon as he dies. 

Treatment. — To remove the worm one begins by administer- 
ing an active dose of calomel followed by another cathartic. The 
first may be given at night, the second on arising the next morn- 
ing. These should be followed by a sufficient quantity of santo- 



■MHI 



186 THE MEDICAL DISEASES OF CHILDHOOD 

nin, which, stops short of producing the full physiological effects 
of the drug. The danger signal is the disturbance of vision that 
makes all objects seem yellow to the sight ; if the drug is pushed 
yet farther, a yellow or reddish discoloration appears in the urine. 

This course may have to be repeated on one or more days until 
the intestinal track is clear. 

Oxyuris vermieularis (synonym : Ascaris vermicularis) is com- 
monly called thread or seat worms. The females only are gener- 
ally seen ; they look like small shreds of white thread. Although 
they are only from eight to twelve mm. long, and one-half mm. 
broad, nevertheless, they are more than twice as large as the male. 
The tail of the female is long and pointed ; that of the male 
is fairly blunt. The eggs are oval and very numerous. They 
are taken into the stomach with raw or unclean fruit and vege- 
tables, or through the agency of dirty hands. In the stomach, 
the embryo rapidly develops, at times in little more than two 
weeks. In the small intestine, the male, after impregnating the 
female, dies, while she descends to the caecum where her eggs de- 
velop. She is then ready to emigrate to the rectum, and out of 
the anus. 

Symptoms. — The main effects which this parasite produces 
are local irritations of the rectum and the skin about the anal, 
perineal, and genital surfaces ; various skin diseases, enuresis, ab- 
normal sexual excitation, disturbances of the gastro-intestinal, 
nervous, and genito-urinary systems likewise show themselves. 

On account of the itching, the child rubs or scratches the af- 
fected parts, contaminating his hands, fingers, and nails with the 
worms and their eggs, and then by bringing the hands to the 
nose or mouth, reinfects himself. In this way the vicious circle 
of contagion may be perpetuated for years. 

The only sure way of diagnosticating the disorder is by seeing 
the worms in the faeces or about the anus and genitals. 

Treatment. — The care of these cases, in order to be finally ef- 
fective, should be continued for six weeks. The principal method 
of cure is the administration of enemata of quassia, salt water, 
garlic, vinegar, and diluted alcohol. Suppositories of quassia or 
garlic and cocoa butter accomplish the same result. Although it 
is impossible to reach the caecum with the small enemata which we 
use in this disorder, nevertheless the repetition of this adminis- 
tration, by getting rid of the parasites in the rectum, will finally 



DISEASES OF THE LARGE INTESTINE 187 

accomplish a cure. In order to throw the enema as high up into 
the bowel as is conveniently possible, the child's position during 
the operation should be on the back, with the hips somewhat 
higher than the shoulders. 

The itching and irritation of the skin, especially at night, yield 
to bathing with carbolic solutions or the use of salicylic acid or 
mercurial ointment. During the whole course of treatment and 
until the parasites are finally eliminated, scrupulous care must be 
exercised to keep the hands and nails clean and the body thor- 
oughly covered at night by such sleeping garments as prevent 
the child from touching the parts and the worms from escaping 
into the bed and about the patient. Where there are several 
children in a family, especial care must be exercised to prevent 
infection. 

Ascarls mystax is a parasite that normally inhabits cats and 
dogs. By handling and playing with these animals, especially if 
they are not kept clean, children may become infected. The worm 
is small, the female not growing beyond twelve ctm. in length, 
and the male half that length. The eggs are covered with a 
reticular formation which is said to resemble the mace on a 
nutmeg. 

The worm is rarely seen. 



Intestinal Colic in Infants 

This troublesome symptom occurs mostly in young infants. It 
depends upon fermentative changes in the intestinal contents by 
which gases are generated. The distention which thus arises, in 
conjunction with more or less muscular spasm, is the cause of the 
pain. These changes in the food are based upon the imperfect 
digestion, especially of proteids. All children are liable to this 
condition, but especially those who are fed upon cow's milk; for 
such milk possesses casein that in coagulation is heavy and diffi- 
cult to digest. Too much sugar, especially cane sugar, in the 
food may cause similar symptoms; fats also may bring about, 
although more rarely, a like result. 

The colic of congestion belongs in a different category. 

The treatment consists in administering enemata that by stim- 
ulating peristalsis will expel the gas. One hundred and twenty 
to two hundred and forty grammes (four to eight ounces) of 



Mmm 



188 THE MEDICAL DISEASES OF CHILDHOOD 

warm water and soap-sucls will usually give relief, especially if 
aided by a hot bath and the application of a hot water bag to the 
abdomen. After the child has become quiet, the intestines 
should be emptied by a full dose of castor oil ; and thereafter such 
changes should be made in the food as will prevent a repetition of 
the pain and spasm. 

A very severe case of colic may possibly be confused with 
volvulus, intussusception, with appendicitis, or intestinal obstruc- 
tion ; but premonitory symptoms of slight intestinal disorders, the 
sudden attack of pain without prostration, and the relief which 
follows an effective enema usually show without delay the real 
nature of the disorder. 

Only in the severest cases does one need to use opium. 

Habitual Constipation 

Young children are peculiarly liable to this disorder because 
their anatomical features, their necessities for a special diet, and 
their physical immaturity predispose them to it. The subject is 
an exceedingly important one and requires serious attention. 

Causes. — The anatomical peculiarities should be well under- 
stood. 1 " During infancy and childhood the intestines grow irreg- 
ularly, by fits and starts, as it were; their position varies from 
that of the adult, and also they are less fixed. The constriction 
which may be found in adults at the junction of the first and 
second parts is commonly absent in infants; the transverse colon 
is relatively low. In the large intestine, up to four months of age, 
the length remains quite stationary. After that time a remark- 
able change takes place; the upper portion begins to grow at the 
expense of the sigmoid flexure, which at birth is nearly one-half 
of the whole large intestine, while at four months it already 
assumes its permanent proportions. The ascending colon in chil- 
dren, owing to the higher position of the caecum and the greater 
size of the liver, is very short. This part of the colon has more 
often a mesentery than in the adult, and also a relatively larger 
portion above the caecum is invested with peritonaeum so that the 
gut is here absolutely free. The caecum alone changes its position 
and relations so much in the course of development that the transi- 
tional nature of childhood is clearly made apparent. 

1 Oppenheim : " The Development of the Child." Macmillan, 1898. 



DISEASES OF THE LARGE INTESTINE 189 

" About the fourth month of foetal life this part of the intes- 
tines is situated near the median plane ; and at a higher level than 
in the adult. As it grows it passes to the right side, in front of 
the second part of the duodenum, and then descends into the iliac 
fossa. Even then it is apt to be placed high up near the anterior 
superior spine of the ilium. A corresponding position is held by 
the sigmoid flexure, hardly any of which is found in the pelvis until 
this bony basin is more widely spread out by later development." 

" The rectum, as one would expect, shows conditions somewhat 
similar to the main part of the large intestine. In the adult it is 
situated entirely within the true pelvis and presents three curves : 
one in the lateral and two in the antero-posterior direction. On 
the other hand, in the infant a large part of the rectum is in the 
abdominal rather than the pelvic cavity ; it is nearly straight and 
occupies a more or less vertical position. Its attachments do not 
extend as high in children, and the reflection of the peritonaeum is 
placed lower down." Thus one can understand how with a nar- 
row, undeveloped pelvis, with a great length of intestine much of 
which lies in the abdominal cavity, with comparatively few fixed 
points to act as points oVappui, and with sectional directions that 
give the least advantage in promoting peristalsis, one can under- 
stand, I think, how liable infants and young children are to con- 
stipation. 

In addition, the muscular fibres in the walls of the intestine 
are often poorly developed. This may be characteristic of the 
whole or a part of the intestine. Moreover, since with growth 
and exercise every part of the child's body may develop favorably, 
such a condition may be transitory, not necessarily characteristic 
of the child's whole life. 

Another important cause is a poorly constituted diet. Breast 
milk that is poor in fat, or too rich in proteids, or deficient in 
quantity may logically give rise to constipation ; for not only are 
local necessities unsatisfied, but also there is apt to be a deficient 
nutrition. When the food is an artificial one, there is still more 
likelihood of constipation ; for milk that differs much from 
mother's milk, that has too hard a curd, that is boiled or steril- 
ized, has an undoubted tendency to bring about this condition. 
Irregularity of habits and lack of attention to the subject have 
also a share of responsibility. 

Pathological conditions, either of the intestines or of the ner- 



i^m^mm 



190 THE MEDICAL DISEASES OF CHILDHOOD 

vous system, — such as intestinal adhesions on the one hand, and 
tubercular meningitis on the other, — are purposely excluded from 
the getiology ; for in them the constipation is merely a secondary 
symptom. 

There are no characteristic lesions, excepting the local irri- 
tation and possible erosion of the mucous membrane which the 
passage of hard, scybalous masses might cause. 

Symptoms. — Outside of the familiar phenomena of constipa- 
tion, the possible symptoms are functional derangements of the 
gastrointestinal track, subsequent nervous disorders, eruptive 
diseases of the skin and scalp, adenitis, prolapse of the rectum, 
intoxication from absorption of matters in the intestine, and press- 
ure effects which may interfere with the action of the diaphragm, 
heart, and visceral circulation. One should especially keep in 
mind fretfulness, irritability, and seeming viciousness of conduct 
that may arise from some small degree of intoxication. 

Treatment. — The first step in the successful handling of these 
cases is the determination of the cause or causes which lie at the 
root of the matter. If an artificial food is the diet, it must be 
made to simulate in its physical and chemical composition mother's 
milk. If breast milk is the food, and if on analysis it proves to 
be deficient in fat, then the requisite amount of cream may be given 
after each feeding. If the milk be too rich in proteids, the daily 
life, diet, and exercise of the mother or nurse must be so regulated 
that the secretion becomes normal. If the milk for any reason 
remains abnormal, it is much better in the long run to wean the 
child without too much delay. 

In older children regulation of the food may be of considerable 
use in promoting a satisfactory intestinal condition. The meals 
must be regular and should include such articles as fruit, break- 
fast cereals, stale bread made from the whole wheat, green vege- 
tables, unboiled creamy milk, and sufficient water. They must 
not contain dried fruits (with the exception of figs), spices, or 
pastry. 

An earnest attempt should be made to promote regular habits. 
The child must go to the closet or vessel at regular times, even 
though he may not at first feel the impulse. The formation of a 
habit is highly desirable, especially since children are so easily 
confirmed in one custom or another. Also the attendant should see 
to it that the patient assumes the proper crouching position which 



DISEASES OF THE LARGE INTESTINE 191 

will enable the muscles to exert all of their power in aiding peri- 
stalsis. In addition, massage and kneading of the intestinal walls 
and coils are of use. A further measure that I have found valu- 
able is abdominal exercise. This is accomplished by teaching the 
child to relax and contract the abdominal muscles. The amount 
of motion which children are able to acquire, thus insuring a 
marked increase in the development of the intestinal muscular 
fibres, is surprising. Also, one may prescribe gymnastic or calis- 
thenic exercises that tend to strengthen these muscles ; and if 
they are followed out faithfully and long enough, they will un- 
doubtedly be beneficial. 

The medicinal remedies are simple. Small enemata of oil or 
glycerin and water are temporary helps. Gluten suppositories 
may be used for a short time. For longer use a combination of 
strychnine, belladonna, and aloin may be given by mouth or in 
rectal suppositories. The former method gives the better result 
and has as its only objection the disagreeable taste of the drugs. 
I have found it possible to give small pills, embedded in fig paste, 
to children of two and one-half years. Such a prescription would 
read : — 



Strychnin. Sulph 

Ext. Belladon. 

Aloin a 

ttJi Ft. massa et div. in pil. no. XV 
Sis. Pil. no. i. t.i.d. 



Metric. 

0.009 
0.036 



Apothecary. 
gr. 3/5 

gr. 3/20 



Each individual case will present peculiarities that a general 
survey of the subject can not and need not foresee. But if the 
physician will show the possession of logic, ingenuity, and pa- 
tience, he will be fairly sure of gratifying results. 

Prognosis. — The outlook, if the cases are well handled, is 
favorable. One must not expect good results too easily or 
quickly. 

Appendicitis 

An inflammation of the appendix usually begins as a primary 
disorder which may spread in various directions ; but the main 
fact to be remembered is that the appendix is the real seat of the 
disease even though neighboring parts may likewise become in- 



^^^ 



192 THE MEDICAL DISEASES OF CHILDHOOD 

volved. For this reason, instead of speaking of typhlitis, peri- 
typhlitis, and paratyphlitis as distinct diseases, we now recognize 
them as being a few of the many manifestations of inflammation 
about the ileo-csecal region. Since almost all of these cases hinge 
upon lesions in the vermiform appendix, we naturally group them 
under the generic term of appendicitis. 

Causes. — The structural differences between very early life 
and adult life have a fairly important bearing upon the occurrence 
of appendicitis. In early childhood the appendix is shaped more 
like a funnel and less like the finger of a glove, than it is in later 
years. It is noticeably long, its mesentery is long, it is more freely 
movable than in later life, and also its location is higher. The 
former is said to lend itself less readily to receiving and con- 
taining concretions than the latter. Also, some stress may be 
laid upon the fact that the appendix is a functionless organ 
whose value was lost in primeval times. Following the nature 
of vestigial structures, it is more easily attacked by patho- 
logical processes than parts which have an active and useful life. 
This would in part account for its frequent disease, especially in 
adults. In infants, however, a modification of the rule would 
hold good. For they in some respects have, as normal features, 
peculiarities that were characteristic of less highly evolved forms. 
Thus, for instance, with the germs of the third molars, which 
develop as late as the fifth year, a fourth molar, a feature that 
generally, if not regularly, occurs in the platyrhine apes, is 
sometimes found. By an analogous force the appendix very 
possibly has more vitality in the first period of life than later on. 
Also, shortly after birth, it has a greater blood supply than in the 
mature person ; for in the latter its mesentery and the included 
arteiw run only to the middle instead of, as in the former, nearly 
to the apex. An additional fact that must be kept in mind is 
that this artery runs along the free concave border of the appen- 
dix. Thus one can easily see that any twisting or pulling, due 
to the pressure of a large amount of gas, to colic or excessive 
peristalsis, is capable of causing sufficient interference with the 
local circulation to bring about congestive and catarrhal changes. 
When this happens, the bacterium coli commune, which appears 
to be harmless in health, attacks the injured tissues. When in 
addition there is a flourishing growth of streptococci in the affected 
region, the resulting intoxication is very serious and of a sort that 



DISEASES OF THE LARGE INTESTINE 



193 



these young patients cannot well withstand. Thus one can see 
that in children there are reasons for both the greater and less 
prevalence of appendicitis than in adults. And it is necessary 
to keep this in mind, because although these young patients 
are supposed to be more exempt from attacks than their elders, 
nevertheless I believe that more exact observation in the future 
will bring about a change of opinion. 

Lesions. — The mucous membrane is swollen, the capillaries are 
injected, there are an emigration of red blood cells and a diapede- 
sis of white. The course of the inflammation goes through the 




Fig. 27. — Acute Appendicitis. X 25. 

various stages to which all mucous membranes are subject. The 
congested condition of the capillaries fades into an acute catarrhal 
appendicitis. This may become resolved, or it may be followed 
by other similar attacks. The exacerbations give rise to a stric- 
ture at the base which is commonly attended by the accumulation 
of mucus, pus, fibrin, broken-down epithelium, bacteria, and faecal 
material. The resulting irritation and pressure may start an 
ulcerative condition or empyaema of the appendix, which in its 
most virulent form may assume the nature of a gangrenous inflam- 
mation. The natural spread of a congestive and catarrhal appen- 



MHH 



■MM 



194 THE MEDICAL DISEASES OF CHILDHOOD 

clicitis results in a localized peritonitis ; but in the ulcerative and 
gangrenous forms a pus process has formed which is located in 
the appendix as a focal point. From this focal point an abscess 
may start which later on will open into the peritonaeum. If, on 
the other hand, the inflammation is so located that the appendix 
becomes fixed by an adhesive process to the parietal peritonaeum, 
the general peritoneal cavity is not invaded. Instead, the inflamed 
part may become shut in by adhesions, or an abscess may be 
formed in the connective tissue back of the peritonaeum, which 
may break through the lumbar region, along the psoas muscle, or 
into one of the abdominal viscera. If it extends above the liver 
and causes a subphrenic abscess, it may work its way through the 
diaphragm and start an empyaema, the pus from which may 
burrow through the lung tissue, and finally be coughed up. 
The various combinations of inflammatory extension and burrow- 
ing of pus are almost without limit. 

Symptoms. — There is usually a previous history of derange- 
ment of the stomach or intestines, with the production of consider- 
able amounts of gas. The characteristic beginning of the disease 
is a chill or an excessive attack of colic. The pain may be referred 
to the whole abdomen ; in fact, it is rare for a child to localize 
it in the right iliac region. It is only when the physician care- 
fully palpates the abdomen — a procedure which should never be 
omitted from the examination of a child with intestinal symptoms 
— that the tenderness is clearly located. This will be sometimes 
found on the line running from the anterior superior spine of 
the ilium to the umbilicus, about three or four ctm. from the 
former point. This localization, known as McBurney's point, 
which occurs almost always in adults, is less frequently seen in 
children. In them the higher position of the appendix, its greater 
length and longer mesentery, make a higher position of the tender 
area possible. For this reason the search for it must extend up 
to the free border of the ribs. In some cases, especially after 
the disease has had time to develop, a fairly large, doughy mass 
may be distinguished in this locality. At the same time, one 
should remember that exceptions may occur, and that the tumor 
in rare cases is otherwise situated. 

The temperature does not run very high, usually ranging from 
38° C. to 39.5° C. (100.5° F. to 103° F.). Generally, infants will 
suffer from a greater amount of fever than older children, and 



DISEASES OF THE LARGE INTESTINE 195 

their prostration will be greater. In children of all ages the 
temperature, especially in the initial stage, is somewhat higher 
than in adults. The respiration and pulse are affected by the 
temperature, the former becoming shallower, and the latter thin 
and wiry as the fever ascends. The tongue is coated, and 
there may be much vomiting, first of food and later of clear liquid 
mixed with bile. The paralysis of the bowel which often pre- 
cedes faecal vomiting is rarely seen in appendicitis excepting where 
the conditions simulate an obstruction of the bowel. The child 
is apt to lie on his back, turned somewhat to the right and 
holding the right knee drawn up so that as little strain as possible 
be laid upon the corresponding rectus muscle. There may be 
an irregular constipation, varied occasionally by short attacks of 
diarrhoea. But this feature is not characteristic enough to deserve 
much importance. There is always marked thirst. 

If the tenderness spreads farther and farther across the abdo- 
men, with accompanying symptoms of suppuration and shock, a 
rupture of the appendix may be suspected. 

Treatment. — The first step in the treatment formerly was the 
emptying of the intestines by repeated small doses of calomel fol- 
lowed by a saline. At the present time objection is made to this 
on the score of the danger that vigorous peristalsis might create. 
Therefore, in place of the calomel, w T e now give a dose of castor 
oil ; and some practitioners, believing that this likewise is danger- 
ous, order no more than an enema. The patient should then be 
kept as quiet as possible, and if necessary opium by mouth or 
hypodermatic injection may be used. An ice bag should be kept 
on the affected region continuously ; in using this, one should 
be careful not to make it too heavy, and in addition the skin 
should be protected by the interposition of a cloth between it and 
the bag. The food must be restricted to modified or peptonized 
milk ; if vomiting is severe, one may have to resort to nutrient 
enemata. The administration of stimulants may at times be 
demanded ; for this purpose good whiskey and small doses of 
mix vomica are of value. 

If fluctuation is detected, or if the tenderness shows a dis- 
position to spread, the opinion of a surgeon w T ill be of value. A 
large percentage of these cases require operation, and a delay 
means greater immediate risk of death, or at any rate an almost 
certain possibility of future attacks. The more I see these cases, 



mmmrnm 



m^m 



196 THE MEDICAL DISEASES OF CHILDHOOD 

the firmer becomes my belief that the operation should be done as 
soon as the indications permit. 

Convalescence should be carefully managed, and the patient 
must not be permitted to take liberties in the way of movement 
or diet until every question of danger is settled. 

Differential Diagnosis. — In distinguishing appendicitis we 
must keep in mind intestinal obstruction and intussusception. 
The main signs of appendicitis are the hard, colicky pains, imme- 
diate rise of temperature, constipation, moderate vomiting, a 
tumor usually on the right side, and pronounced thirst. In ob- 
struction, since there are at the beginning no inflammatory lesions, 
there will be no fever, no vomiting, and gradually appearing pain. 
In intussusception the tumor is commonly on the left side, pain 
appears only late in the sickness, the temperature rises no more 
than slightly or may be subnormal, the vomiting is apt to be 
stercoraceous, and there are mucous movements slightly stained 
with blood. 

Prognosis. — The prognosis is, on the whole, better under surgi- 
cal than medical treatment. Some surgeons report a mortality as 
low as two per cent. Children stand the operation well, and enjoy 
a fairly rapid convalescence. 

Proctitis 

The rectum, in the presence of inflammation in the intestine 
above, sometimes becomes affected in a like manner. In this way 
one may account for the large majority of the cases of proctitis. 
The extended disorder is of the same nature as the original com- 
plaint, and needs very little differentiation from it. In some few 
cases, however, a proctitis may start as a new disease, after a 
periproctitis, as the result of injury from a syringe-nozzle, irritating 
suppositories, pin worms, gonorrhoeal infection from the vagina or 
criminal violence, and by means of foreign bodies of all sorts. In 
addition, wounds of the rectum may be attended by a variable 
amount of inflammation. Diphtheria may invade the rectum, and 
some of the other acute infectious diseases, as well as tuberculosis 
and syphilis, may also cause disturbance, although rarely in this 
locality alone. 

The symptoms do not differ much from those of an ileo-colitis, 
with the exception of greater heaviness, pain, and tenesmus which 



DISEASES OF THE LARGE INTESTINE 197 

are referred to the region of the rectum. There is a formation of 
mucus that is sometimes streaked with blood. The straining may 
be so great as to produce a prolapse of the mucous membrane of 
the rectum. 

The membranous form is apt to be severer than the catarrhal, 
and almost always is characterized by the presence of streptococcic 
infection. The only method of sure differentiation is finding 
pieces of membrane in the stools. 

As an extension of an ulcerative inflammation from above, or 
on account of an exaggeration of a catarrhal proctitis, the rectal 
mucous membrane may become riddled with superficial ulcers. 
In some cases these eat their way through the deeper layers of 
the bowel. Usually the attention is drawn to them by marked 
pain and variable amounts of haemorrhage. Often the ulcers may 
be seen on ocular examination. 

The treatment of proctitis includes the general care of the 
diet, rest in bed, and the application of such means as will keep 
the rectum approximately clean and bearably quiet. This can 
be accomplished by flushing out the bowel with a warm saturated 
solution of boric acid, followed when necessary by suppositories 
of cocaine hydrochlorate or opium. In the later stages astringent 
injections may be used, although in most cases one can get along 
quite well without them. The general scheme of treatment is, on 
the whole, the same as in ileo-colitis, with the possible exception 
of those cases where there is a local cause at fault, such as a 
foreign body or pin worms, in which case the offending cause must 
first of all be removed. 



Prolapse of the Anus and Rectum 

A sharply differentiated nomenclature will distinguish between 
a prolapse of the anus and one of the rectum. In the first named 
there is a protrusion of the anal mucous membrane ; in the latter 
there is a descent of the whole wall of the rectum ; either may 
project one or more centimetres. In the beginning the protrusion 
occurs only on defaecation, but later on it may happen at any time 
of strain or movement. 

Causes. — The condition has two main serological factors : one 
is straining in having a movement, the other is physical debility. 
Such complaints as the various functional and organic derange- 



■■■■■■^■^^■■^1 



198 THE MEDICAL DISEASES OF CHILDHOOD 

ments of the large intestine, phimosis, cystic calculi when they 
attack rachitic and poorly nourished children, especially those 
under three years of age, very easily bring about a protrusion of 
the rectal structures. 

Treatment. — Each time the prolapse occurs it should imme- 
diately be replaced after being oiled. Where much swelling is 
present, the application of ice will often reduce the size enough to 
permit reposition. In a few cases it may be necessary to anaesthe- 
tize the patient and stretch the sphincter. 

The most troublesome part of the treatment consists in trying 
to overcome the constant recurrence of the disorder. To meet 
the requirements the child should defsecate while lying on the back 
or side, so that he may not strain too much. The nurse or mother 
may aid him in this by holding the buttocks with a light but firm 
pressure. After the movement the child should continue in the 
recumbent position for a quarter or half an hour to allow the bowel 
to become quiet. At the same time the movements must not be 
constipated, and to accomplish this end the diet must be regulated 
and mild cathartics administered. After the movement, a T ban- 
dage should be adjusted or the buttocks be held together with 
adhesive plaster. Astringent injections may in some cases be of 
use, but as a rule one can do without them. Most of all is this 
true if one recognizes the cause of the prolapse and abolishes it. 
In the majority of all cases there is marked general weakness 
which must be earnestly combated. 

In exceedingly obstinate cases occurring in older children, it 
may be necessary to cauterize the prolapsed bowel with the 
Paquelin cautery or nitric acid. Before being replaced it should 
be well oiled, and in the lumen a small plug of gauze may be placed 
to keep opposing surfaces apart. Only in the very severest cases 
is a more radical operation required. And when the proper 
measures are employed, the prognosis is good. 

HAEMORRHOIDS 

This condition is not often seen in the general practice among 
children ; in hospitals and dispensaries it occurs somewhat more 
frequently. It is apt to follow chronic constipation or other dis- 
orders which entail much straining at stool ; this factor com- 
bined with an atonic condition of the rectal mucous membrane 
is sufficient to cause local dilatation of the blood-vessels. In 



DISEASES OF THE LARGE IXTESTIXE 199 

some cases there may be small haemorrhages, especially if the 
tumors are internal. 

The symptoms are protrusion of the haemorrhoids while at 
stool or straining, some pain and occasional haemorrhages. 

The treatment consists in keeping the movements loose and 
in the use of astringent ointments. At the same time the diet 
should be regulated and tonics administered. In cases of neglect 
the disorder may be so firmly seated as to call for operation. 

Haemorrhoids have been confounded with rectal polypi, pro- 
lapse of the rectum, and even invagination of the intestine. A 
short time since I was called to see a girl of four and a half years 
of age in whom a diagnosis of haemorrhoids had been made. 
Examination showed an internal pile and a rectal polypus ; the 
straining produced by the latter was doubtless the cause of the 
haemorrhoid. When the polypus was removed the haemorrhoid 
disappeared without further treatment. 

Rectal Abscess 

Rectal abscesses are either ischio-rectal or marginal. They 
arise from traumatism of some sort, or from absorption of toxic 
matter through lymph channels. In addition, some few cases 
of extension from a tubercular area occur in this region. Intra- 
mural abscess of the rectum and perirectal abscess are local sub- 
divisions of the general subject. All these special forms usually 
attack children who are in poor health. 

The symptoms are the same as in adults, and consist in a feel- 
ing of heaviness and pain in the perineal and rectal region ; fre- 
quently there is brawniness, followed by fluctuation, wdiich may 
be detected on palpation. There may finally be an escape of 
pus. 

The treatment is surgical ; free incision should be performed 
as soon as one detects signs of pus. 

N^svus of the Rectum 

No more than a mention of this condition is needed. It is of 
rare occurrence, and is characterized by haemorrhage from an other- 
wise unimpeded bowel. 

Its treatment consists in the applications of the Paquelin 
cautery. 



immm 



200 



THE MEDICAL DISEASES OF CHILDHOOD 



Rectal Polypus 

A pedunculated tumor of the rectal mucous membrane is a not 
very uncommon complaint in children of all ages and conditions. 
In character it may be adenoid, cystic, or fibrous, the first being 
the usual form. Its pedicle is of varying length. Usually it is 
situated near the sphincter ; cases, however, of much higher loca- 
tion have been reported. The child complains of straining and 




!&»>' 



Fig. 28. — Rectal Polypus, x 100. 



tenesmus, occasionally of slight pain. Some blood and mucus 
may be passed with the stools. 

One can be sure of the diagnosis only by seeing or feeling the 
polypus. It is cured by twisting off the pedicle and touching the 
stump with a Paquelin cautery or nitric acid. In some cases it 
may be possible to withdraw the tumor, tie off the pedicle near 
its base, and amputate above the ligature. 

Rectal polypi must be differentiated from h&emorrhoids and 
prolapse of the rectum. The diagnosis is so easy that nothing 
more than careful attention is needed to confirm it. 



DISEASES OF THE LARGE IXTESTIXE 201 

Fissure of the Anus 

As a result of scratching the anus, of very hard stools, of 
traumatism produced by syringe nozzles and foreign bodies in 
general, the mucous membrane of the anus may be fissured in a 
vertical direction. The result is considerable pain on defalcation, 
straining, or manipulation. 

The active cause should if possible be discovered and abolished. 
The movements should be kept loose, and a five per cent or ten 
per cent icthyol ointment should be applied, and kept in place 
by a pad and T bandage. In severe cases it may be necessary to 
touch the fissure with nitrate of silver, and in the worst instances 
one may have to stretch the sphincter. 



■■■^^■fl 



CHAPTER XII 

DISEASES OF THE PERITONEUM 

Ascites 

The occurrence of this symptom may mean either local or 
general disease. A knowledge of the causes which produce it 
is the readiest means of referring the responsibility to its proper 
source. For the most part the effusion is caused by disease of 
the liver, or a condition which gives rise to pressure upon the 
portal circulation. In other cases it is due to cardiac disease 
pressure upon the inferior vena cava, to pulmonary, peritoneal, 
and occasionally nephritic disease. Marked anaemia may be at the 
root of the trouble, or tumors of the abdomen and the nearby 
viscera may be the cause. Finally, it may be a local symptom of 
a general anasarca caused by marked cachexia. 

Chylous ascites is the name applied to the presence in the 
abdominal cavity of a milky -colored fluid containing a large per- 
centage of fat. Its causation is obscure ; and although we know 
that it may follow perforation of the thoracic duct or filariasis, 
nevertheless this knowledge does not explain all the cases that we 
meet. 

The principal inconvenience which ascites gives is that due to 
pressure. As the primary disease which causes it disappears, it 
likewise is apt to diminish. Where it persists the usual treatment 
has consisted in the administration of salines, followed if necessary 
by tapping. A more satisfactory method would be the operation 
of laparotomy. 

Acute Peritonitis 

Causes. — An acute inflammation of the serous membrane lining 
the abdominal cavity and covering the viscera therein contained 
is not a rare condition in childhood. Sometimes it is seen at 
birth ; such cases are generally thought to be syphilitic, although 

202 



DISEASES OF THE PERITONEUM 203 

I have found seeming exceptions to the rule. It is possible that 
infectious disease in the mother before delivery, such as measles, 
may be the cause. In infants of a few days or weeks the cause is 
usually an indirect one, such as septic inflammation of the umbilical 
vein, or a disease, e.g. measles, that is able to produce a compli- 
cating affection of the serous membranes. The essential condition 
seems to be the active presence in the body of the streptococcus, 
staphylococcus, pneumococcus, or bacterium coli commune in such 
locations that it can find its way through lymphatic channels to 
the peritoneal cavity. Most cases occur in children of a greater 
age, of four or more years. Here the disease may be traced to 
falls, blows, and injuries of the abdomen, disease of the abdominal 
viscera, such as rupture, intussusception, volvulus or inflammation 
of any part of the intestine ; pathological conditions of the 
stomach, vermiform appendix, liver, kidneys, spleen, pancreas, 
pleura, and lymphatic glands ; hydatid cysts, pyogenic diseases 
of the bladder, uterus and its connections, and male genital track; 
inflammation of adjacent bony structures, and the acute infectious 
diseases, including septicaemia. 

Lesions. — In the first stage there are in the peritoneal mem- 
brane an active congestion, a heightened red color, and a prolifera- 
tion of endothelial cells. This is followed by the production of 
fibrin, serum, and pus in variable quantities. The milder cases 
have but little pus, and so have been termed fibrous or serous. 
Nevertheless there is practically always a formation of pus cells 
which collect on the surface and work their way in between the 
endothelial cells. The surface is likewise studded with small or 
large masses of fibrin. The peritoneal cavity contains serum in 
variable quantitj r in which there may be uncertain quantities of 
bacteria, pus cells, and endothelial cells. After the disease has 
been in existence for a week or more, the connective tissue cells 
may be increased to a marked degree. In addition, the fibrin may 
cause neighboring folds of intestines to adhere to each other by 
bands which may finally become permanent adhesions. 

Symptoms. — The disease may or may not be ushered in with 
a chill. Vomiting is apt to show itself and to become worse when 
food is administered ; there may be diarrhoea or a decreased peri- 
stalsis — for one cannot formulate a hard and fast rule in regard 
to this detail. The urine is scanty, high-colored, and may burn 
in passing. It often contains considerable quantities of indican, 



1M 



204 THE MEDICAL DISEASES OF CHILDHOOD 

and some acetone. The child is plainly in much pain, which he 
involuntarily tries to diminish by flexing the legs upon the 
abdomen, thereby reducing strain upon the abdominal structures. 
His attempts are evidently unsuccessful, and his suffering becomes 
progressively more intense. Any form of examination, pressure, 
movement, or peristalsis is scarcely bearable ; even the act of 
approaching his bed frightens him. The pain is apt to come in 
waves and spasms, rather than in one continuous stream. There 
is much prostration, the face has an anxious, sunken, and drawn 
look, the pulse is small and rapid, the respiration is quick and 
shallow, and the temperature ranges from 1 or 2 degrees above 
normal to 41° C. (about 106° F.). The high temperatures are 
commonly present in cases of associated intestinal disorder, while 
those of the uncomplicated disease show moderate pyrexia. 
Occasionally a very toxic case will give a normal or a sub-normal 
temperature. The abdomen is swollen and typanitic over its 
whole surface, except where the peritonitis is distinctly localized ; 
such an area is often recognized by the circumscribed tenderness 
and pain. The abdominal swelling varies according to the thin- 
ness of the walls and the amount of tympanites. The latter 
element may be distinguished not only by the exterior form, but 
also by the hyper-resonant percussion note ; on the other hand, an 
overloaded state of the intestines or the presence of a considerable 
amount of fluid may make the note fairly dull. These remarks 
are most applicable to a general peritonitis, in which there is a 
moderate distribution of the symptoms. At the same time one 
must keep in mind that a localized peritonitis may at any time, 
and often does, become general. In some cases there is a succes- 
sive involvement of one part after another. 

When recovery takes place, it shows itself by gradual amelior- 
ation of all the symptoms. One must be prepared for a slow and 
tedious convalescence which is characterized by a train of intestinal 
derangements. 

Treatment. — The first step is to empty the gastro-intestinal 
track, preferably by small and rapidly repeated amounts of calomel 
followed by a saline. Thus one may order 0.006 gramme (y 1 ^ grain) 
of calomel for six to ten doses at half hourly intervals to be fol- 
loAved by a sufficient amount of the sulphate or citrate of magne- 
sium to flush out the intestines. Hot stupes may be continuously 
employed. As soon as the bowels have moved sufficiently, enough 



DISEASES OF THE PERITOX.EUM 205 

opium or morphine must be given to quiet pain and peristalsis. It 
may often be necessary to administer this drug hypodermatically 
in order to avoid disturbing the stomach. This object will be still 
further effected by a rigorous care in feeding the child ; the diet 
must be confined to fluids, and often it will be necessary to pre- 
digest all food until convalescence sets in. Since the patient 
obtains a certain amount of ease by flexing the knees, this position 
may be maintained by placing a folded pillow under them. A 
further degree of comfort may be obtained by allowing the child 
to lie with his hands above his head. If the signs show a notice- 
able increase of fluid in the peritonaeum, especially if pus infection 
seems to be growing, the treatment becomes surgical. 

Prognosis. — The outlook is always doubtful, and from day to 
day the chances for recovery may change in material degree, 
largely according to the amount of pyogenic intoxication. The 
chances of recovery vary according to the area involved, the 
child's vitality, and the amount of the septic element. One can 
easily see that each case must be judged by itself, and that no 
single opinion can be universally applicable. 

Differential Diagnosis. — The main facts to keep in mind are 
the history, the gradually increasing pain and tenderness, the 
elevated temperature, the hard abdominal wall, and the flexed 
knees. From this group of symptoms we must differentiate colic, 
acute intestinal obstruction, enteritis, renal or biliary calculus, and 
neuralgia. Colic gives a sharp, acute pain, which doubles the 
patient up ; there is no fever or prostration, and the patient is 
unable to lie quiet. An enema or a cathartic will promptly give 
relief, and clear up the diagnosis. In acute obstruction there is at 
first no fever, no abdominal tenderness, the belly wall is not tense; 
there will be copious vomiting at first, which later on becomes 
stercoraceous. In the beginning there may be a number of small 
movements ; and when they have ceased, one may at times feel 
an abdominal tumor. Enteritis should rarely be a confusing 
factor, since its tenderness and pain are not so marked, nor is the 
abdominal wall so hard and rigid. Renal calculus and neuralgia 
give no material elevation of temperature, no general tenderness, 
no characteristic position of the knees, no regular history. In 
appendicitis the distinct localization and the tumor are usually 
sufficient to sIioav the nature of the trouble. 



206 THE MEDICAL DISEASES OF CHILDHOOD 

Chronic Peritonitis 

A chronic inflammation may follow an acnte process, may 
complicate chronic disease of the heart, lungs, spleen, or liver, 
or may occur as an original sickness. The tubercular form is 
described under the head of tuberculosis. 

Lesions. — The changes are not always the same : in a few 
cases they consist for the most part of a proliferation of the 
endothelial cells ; the connective tissue is increased at the same 




Fig. 29. — Perihepatitis. X 50. 
Occurring with Chronic Peritonitis. 

time. In addition there may be more or less extensive adhesions, 
particularly in the neighborhood of a focus of pus. In other 
cases there is a thickening of the peritonaeum with the production 
of much connective tissue, a deposition of fibrin, the formation 
of adhesions between opposing surfaces of peritonaeum and intes- 
tines, and the presence in the cavity of an increasing quantity 
of clear or purulent serum. At times the capsules of the liver, 
spleen, and kidney may be involved and become very much 
thickened, especially when the process has been localized. Evi- 
dently in such cases the inflammation has gradually spread until 
it involved the whole peritoneum. 



DISEASES OF THE PERITONAEUM. 207 

Symptoms. — If the process follows an acute attack, the child 
after defervescence does not seem to recover. He is unable to 
exert himself and complains of tenderness and some pain in the 
abdomen. A variable quantity of fluid collects in the cavity, and 
the whole abdomen begins to be distended. At times there are 
areas which continue to be painful or tender, even when the main 
symptom is the ascites, which doubtless represent foci of severe 
inflammation or adhesions that have been put on the stretch. 




Fig. 30. — Perisplenitis. X 50. 
Occurring with Chronic Peritonitis. 

There may be no fever or only a slight evening rise. The general 
nutrition is poor, and the child is liable to have many coincident 
symptoms in other organs as well as a proneness to contract inter- 
current disease. The coincident symptoms are commonly the 
ones that attract most attention, and give most trouble in the 
successful treatment of the general condition. 

Treatment. — If improvement does not follow the use of 
tonics, careful nursing, and a moderate amount of salines, and 
if the fluid does not increase in quantity, laparotomy is advisable. 
I believe that this measure has certain advantages over aspira- 
tion ; by it one would avoid the tedious recurrences of fluid 
after tapping, and thereby avoid much loss of strength and 



208 THE MEDICAL DISEASES OF CHILDHOOD 

vitality. In addition, it is wiser, surgically, to have a fairly 
large open wound, in the manipulation of which the operator 
can see what he is doing, rather than to make a puncture more 
or less blindly, and thus carry a possible infection in inserting 
or withdrawing the instrument. 

After the fluid has been disposed of, the physician must for 
a long time keep the child under observation, carefully regulating 
tonics, food, exercises, and hygiene. 

Prognosis. — The outlook is better than in the active acute 
form. The patients are generally in the second half of childhood, 
and so have greater vitality to draw upon than if they were 
younger. The main factor in the prognosis is the differentiation 
of the simple from the tuberculous form. 



CHAPTER XIII 
DISEASES OF MALNUTRITION* 

Laryngismus Stridulus 

The penalties of malnutrition are so far reaching that it is 
almost impossible to set a limit to the potential effects of the dis- 
order. We are apt to think of this condition as, for the most 
part, being confined to strongly marked and familiar pathological 
states such as gastro-intestinal disorders and poorly nourished 
bones, and there seems to be difficulty for most people to conceive 
that the influence of malnutrition extends beyond these limits. 
As a matter of fact the more closely one looks at the phenomena 
of development, the more one is impressed by the prevalence of the 
effects of defective nourishment. 

Causes. — A striking instance of this generalization is the 
neurosis called laryngismus stridulus, spasm of the glottis or 
internal convulsions. The disorder occurs among imperfectly 
nourished children whose deficiency may result from the evils 
of luxury as well as those of poverty, from exposure or the 
confinement of too sedulous care. Thus the artificial life which 
is imposed upon so many babies in cities makes the condition 
more prevalent there than in the freer circumstances of the 
country. As a matter of experience we know that it occurs 
somewhat more often in boys than in girls ; but the reason of 
this is hard to find. That it is confined to the first year or two 
of life may depend upon the unstable and easily disturbed 
nervous equilibrium of that time, in which the transitional 
character of the child's physical being is so plainly evident. 

Some of the abnormalities, such as enlarged and irritated 
glands and a disturbed detention, which have so regularly been 
cited as causes, are no more than proofs of this. For cases have 
occurred time and time again without their possible influence ; 
while, on the other hand, the debased physical condition which 
causes this neurosis is likewise able to have as some of its partial 
p 209 



210 THE MEDICAL DISEASES OF CHILDHOOD 

characteristics these and other similar disorders. The elements 
of heredity, so regularly mentioned as a more or less active cause, 
acts mostly in the way of providing a possible weakness of 
assimilation and excretion ; but it is very apt to be helped out 
by unwise general care of the child, which commonly, in the 
absence of intelligent effort and instruction, blights one baby 
after another in the same family. Often enough the increase in 
maternal wisdom and knowledge is not in direct ratio with the 
number of births in the family. 

Lesions. — There are no known local lesions in this disorder. 
In fact, the spasm of the glottis, or adductor spasm of the larynx, 
which is so startlingly evident as to draw the observer's attention 
to itself and away from other characteristics, is merely one of the 
symptoms. Thus, some clinicians speak of a diaphragmatic form, 
of a laryngeal form, of a mixed form, of a form which involved 
the pharyngeal as well as the laryngeal muscles, of cases in which 
the neurosis is so widely diffused that it shows itself in a spasm of 
the carpo-pedal muscles. And, in addition, acute observation will 
convince one that other muscular tissues, such as those of the 
thorax, the abdomen, the eyes, and probably the heart, may be 
involved. Indeed, it is hard to draw a line at the possible con- 
vulsive effects, for, more or less directly, any portion of the body 
may be involved. 

Symptoms. — The most prominent symptom is the spasm of 
the glottis, which in proportion to its completeness stops respi- 
ration until relaxation occurs. The attacks usually begin mildly,, 
so that, as the low form of intoxication which comes from mal- 
nutrition increases, the spasms likewise increase. The more 
strongly marked paroxysms come at night with all degrees of rapid- 
ity of recurrence. In the milder forms of the disorder the glot- 
tis closes completely or nearly so for a few seconds, so that there is 
practically a total stoppage of respiration ; then it opens slightly 
and the air rushes through with a convulsive, crowing sound. In 
severe attacks the apnoea is of longer duration, the muscles are 
convulsively fixed, the skin becomes cyanotic and slightly puffed, 
and finally the child drops back unconscious. In extreme cases,. 
and where the intoxication is evidently extreme, plainly marked 
general convulsions supervene, in some instances followed by 
death. In these cases it is hard to say in what degree the fatal 
termination is due to asphyxia or to the general intoxication. 



DISEASES OF MALNUTRITION 211 

Treatment. — The treatment looks to the breaking up of the 
spasm and the removal of the physical conditions which cause it. 
Hot or cold applications, used separately or alternately, or the 
various well-known expedients for restoring impeded respiration, 
will be of service in ending the convulsion. To quiet the irritated 
nervous system, antipyrin or bromoform or bromide of soda is effi- 
cient. The gastro-intestinal track should be thoroughly emptied, 
and then the main idea of treatment should be carried out. This 
consists in minutely examining every detail of the child's life, in 
carefully searching for faults in the methods of feeding, in the 
circumstances of sleeping, clothing, exercise, hygienic and moral 
control. Tonics, when needed, — and they usually are, — should 
be given until the child is in a normal, strong state of health. The 
organic preparations of iron or the compound syrup of hypophos- 
phites, for such children as can digest it, are highly desirable. 
But the main thing is to regulate the child's general mode of life 
so as to diminish sources of weakness and improve the sources of 
strength. 

Prognosis. — In most cases the attack passes off without any 
more serious effects than temporary exhaustion ; and for this 
reason we commonly regard the disease as not especially danger- 
ous. Nevertheless, one should not forget that the spasm may be 
severe and long enough to bring about a fatal result. 

Simple Atrophy 

This is a condition of extreme malnutrition which results from 
bad methods of feeding and unhygienic surroundings. In for- 
tunately situated families it is rare, but in large institutions, as 
well as among the poor and ignorant frequenters of dispensaries, 
it is common. Such sources supply a continuous stream of these 
cases in some of the various stages of the process ; they are com- 
monly unsatisfactory cases to treat, not because the condition is 
necessarily fatal, but rather because the original circumstances 
of ignorance and poverty are extremely difficult of amelioration. 

Causes. — Simple atrophy is practically always acquired. The 
child at birth may seem healthy and well nourished. Then, as 
the result of the mother's milk being poor in quality or quantity 
or both, or on account of a substitute food which is too difficult to 
digest or absorb, a process of starvation begins. Unhygienic en- 
vironment supplies the missing unfortunate element of decline 



212 THE MEDICAL DISEASES OF CHILDHOOD 

until the child is ready to slip from this life to the next with the 
least show of resistance. In other cases the process of malassimi- 
lation may start from some exhausting sickness, such as gastro- 
intestinal disease, syphilis, bone-disease, which so far depresses 
the child's vitality that the economy is unable to perform its 
functions, and assimilation practically stops. Thus, to cite 
examples, in a case of severe septic infection following circum- 
cision, I saw a most impressive instance of this truth ; and again, 
after a most trying broncho-pneumonia and pleurisy, I saw the 
same experience repeated. As a rule, however, the disorder be- 
gins in the gastro-intestinal track where the functional disability 
is so long continued, with its attendant train of far reaching 
symptoms, that a sort of starvation ensues. 

Symptoms. — While the different degrees of severity bring out 
appropriate signs, nevertheless the main tendency is in all alike. 
The child begins to lose flesh, in some cases so rapidly that it 
seems almost to melt from the bones. But whether the loss is 
rapid or slow, he finally comes to be markedly emaciated, the skin 
hangs in sagging folds, the face looks grotesquely old, furrowed, 
and puckered. The skin generally is dry, harsh, cool, and clammy. 
Here and there, and especially on the face and head, it begins to 
assume a brownish yellow color and a thin, dry crust. At this 
time the patient is very apt to suffer from exacerbations of gastric 
or intestinal disorders which necessarily show their logical symp- 
toms. In this way the number of fsecal movements may be in- 
creased or diminished, although the ordinary course of the disease 
gives a moderate number of large stools. For the same reason 
the color, which generally is light, may be changed to a greenish 
or a clayish hue. Frequently there is no marked vomiting except 
in the presence of intercurrent gastric disorder. The child is con- 
stantly hungry, and, until he becomes quiet from exhaustion, 
shows it by restlessness and crying. 

The course of the disease is steady, and the symptoms from 
week to week increase in severity. The temperature is usually 
normal or subnormal ; nevertheless this rule will often be modi- 
fied on account of the susceptibility of these children to inter- 
current disorders, any of which may regularly bring an elevation 
of temperature. The fontanelle may be slightly depressed, 
anaemia be marked, and oedema progressive. The patients are 
liable to complicating disorders of the skin, mouth, congestive 



DISEASES OF MALNUTRITION 213 

bronchitis, and hypostatic inflammation of the lungs, and occa- 
sionally to functional nervous complaints. 

Treatment. — The preventive treatment is obvious : merely to 
avoid errors in feeding and hygiene. If this were done, there 
would be few cases of marasmus. In the presence of the disease 
drugs are of little use ; for the disease is a mode of starvation. 
The main object is so to modify the milk that the patient can digest 
and assimilate it. Empirically we have found that the best com- 
bination is composed of a very small percentage of fat, a moderate 
percentage of proteids, and a high percentage of sugar. Beyond 
these details one cannot well go ; for one child cannot digest more 
than 0.75 per cent of fat, while another may thrive on 1.5 per cent. 
The same rule holds good for the proteids and sugar. The best 
plan is to begin with very small percentages and increase them as 
the patient's condition permits. The quantity at each feeding 
should be small ; and in order to ascertain whether it is nourish- 
ing the child, his weight should be carefully ascertained twice a 
week or oftener. At the same time it is advisable to examine the 
stools macroscopically and microscopically, and adapt the treat- 
ment to the indications thus ascertained. If the child does not 
gain, the food must be continuously modified to suit his needs. 

The question of ventilation, exercise, and hygiene in general is 
almost as important as food. The child must be bathed daily, 
his sleeping room should be thoroughh' ventilated and well 
lighted, and the care of his body should be scrupulously exact. 
Best of all, he should be kept in the country as much as possible. 

The treatment of all temporary and intercurrent diseases must 
be as simple as possible. 

Prognosis. — The forecast of these cases is purely relative. If 
the disease has not run too long, if the child is not too young and 
weak, and if the requirements of treatment are carefully and 
logically carried out, the child has a fair chance to live and attain 
a good development. The farther these suppositions are from 
fulfilment, the poorer is the result of the case apt to be. 

Differential Diagnosis. — The main error into which one may 
fall is to confuse simple atrophy with tuberculosis. The latter is 
more apt to give appreciable pulmonary symptoms or other signs 
of metastatic invasion, and in addition is always attended by an 
evening rise and a morning fall of temperature. Observation for 
a few days will generally exclude one or the other of the diseases. 



214 THE MEDICAL DISEASES OF CHILDHOOD 

Rachitis 

Causes. — Rickets is a condition of hypotrophy plus the effects 
of the deviations from the normal process of growth. These devi- 
ations, as well as the hypotrophy itself, are of various kinds and 
degrees, so that the resultants are likewise variable. In the pres- 
ence of such imperfect and abnormal states of nutrition many 
inflammatory states — acute and chronic, active and passive — 
are both possible and probable. The statement of what the dis- 
ease is bears with it an understanding, to some extent at least, of 
its aetiology. It is not hereditary, nor if one wishes to be exact 
can it be called congenital. The very rare cases of so-called 
foetal rickets, the achondroplasia of Parrot and the chondro- 
dystrophia of Kaufmann, should be put in a different category. 
These instances of " dwarfism " or " infantilism " are really ex- 
amples of physical deficiency, comparable to certain forms of 
mental deficiency; but the continued use of improper food, 
and a life passed in a badly arranged environment, especially 
in the earliest and most easily disturbed age, will usually bring 
on the rachitic condition. It takes a not extended experience in 
hospital and dispensary practice to form a good idea of the requi- 
sites for producing the disease. One very soon notices that almost 
all of these cases have been fed on artificial foods, and that only in 
the rarest instances has the patient been nourished at the breast. 
The usual diet thus includes a small quantity of fresh milk and 
a large quantity of dessicated substances that are rich in sugars 
and starches. The normal milk ingredients which commonly are 
lacking are fats and proteids, and sometimes mineral salts. Even 
where fresh cow's milk is used, the differences in chemical com- 
position between it and mother's milk so often set up functional 
disturbances of the stomach and intestines that digestion and 
absorption are rendered impossible, and the infant is in the same 
position as he would be if fats and proteids were excluded from 
his food. 

These errors in diet are most commonly found among the 
poor who may have difficulty in obtaining and modifying good 
milk. On the other hand, the complaint may be seen in the chil- 
dren of wealthier persons who, on account of indolence or igno- 
rance, commit practically the same faults. These patients are 
fed on cereals, vegetables, sugars, and starches ; they are coddled 



DISEASES OF MALNUTRITION 215 

and pampered and deprived of opportunities of obtaining suffi- 
cient light and air. This is the state of affairs that exists widely 
among the poor, especially in large cities, the cubic space of 
whose rooms is small, whose apartments are too often dark and 
poorly ventilated, and whose opportunities of breathing the air 
of country, seashore, and park are sharply limited by necessity, 
ignorance, or indolence. Such deprivations bear most heavily 
on children in temperate climates whose parents have emigrated 
from warmer lands. For the natural habitat of rickets is in 
these temperate zones where the changes in temperature are 








■n 

4 





. / 

/ 


i^*- 




. 31. — Normal Bone. X 220. 





great, where there are weeks and months of cold and dull 
weather which bring with them confinement and suffering. An 
additional danger comes from the weakened bodies which the 
conditions of life impose upon the parents ; for such people, 
although they do not transmit the disease itself, do transmit to 
their offspring a deficient vitality which is easily influenced by 
unfortunate environmental conditions. In the same fashion, any 
other circumstances which diminish the patient's vital resistance 
will produce a similar result. In this way hereditary syphilis 
makes a child more easily subject to rachitis than he otherwise 



BH 



216 THE MEDICAL DISEASES OF CHILDHOOD 

would be. Again, exhausting diseases, such as severe gastro- 
intestinal disorders, may in the same way accomplish a similar 
end. In short, the only positive causes of rickets that we know 
are the errors in diet above mentioned, with or without unfor- 
tunate environmental conditions. 

Lesions. — All through the body the changes exist in varying 
degrees, affecting the bones, joints, muscles, nerves, and viscera. 
Those of the bones are most prominent, and generally have been 
thought to be the characteristic ones of the disease. While all 




Fig. 32. — Rachitic Bone. X 220. 

the bones may be and usually are involved, nevertheless the long 
ones show the principal modifications in both structure and form. 
The process of growth is changed ; the increase in true bone 
structure is slow, irregular, and partial ; the increase in the car- 
tilaginous cells and those on the periphery of the bone is, on the 
contrary, very marked in the epiphysis as well as to a less extent 
along the shaft. In normal growing bone the medullary cavity 
becomes enlarged through the length of the bone by the gradual 
and regular absorption of the medullary layers of bony cells. In 
rickets, the absorption and consequent dilatation occur unevenly 



DISEASES OF MALNUTRITION 217 

both in regard to time and extent. In the part between the epi- 
physis and diaphysis the cartilage cells are not placed in regular 
rows ahead of the zone of ossification, but on the contraiy are 
piled up in irregular formations in which there may be some 
calcific areas, or none at all. The blood-vessels of the whole 
bone are large and plentiful instead of being small and few. The 
area of ossification is likewise irregular, and cartilage cells may, 
by means of the microscope, be seen scattered through it. The 
sharp differentiation between the bony and cartilaginous areas 
is not always preserved, and the integrity of both is deficient. 
Under the periosteum a similarly asthenic condition exists. The 
central strata of cells are proliferated, and studded irregularly 
with varying areas of calcific deposition. Here, as well as in the 
midst of the bony structure, there is a spongy, irregular growth 
which takes away from the normal strength. This loss is accen- 
tuated on account of the increased size of the central cavity of 
the bone, and the fragile and unstable condition of its surround- 
ing layers. The medullary substance is congested, swollen, and 
at times considerably inflamed. 

As the result of these changes, the epiphyses are enlarged and 
irregular in form, the shafts or bodies are lacking in true bony 
tissue, and therefore are much softer than the normal. A graphic 
way to represent this is to remind the reader that such bones lack 
one-quarter or even one-half of their whole percentage of calcium 
salts. It is therefore easy to understand how they may be pulled 
out of shape by muscular traction and atmospheric or adventitious 
pressure. The ribs, on account of their long and narrow form, 
are the most easily affected ; and after them, the long bones of 
the arms and legs. The epiphyses are clubbed and knobbed, the 
shaft may be thickened and bent out of shape, either forward or 
to the sides. Similar processes may attack the pelvic and cranial 
bones, which, on account of their softness, their irregular thinning 
and thickening, and the mechanical strain jDut upon them, become, 
the one narrower, the other flattened (rachitic pelvis and cranio- 
tabes). 

The ligaments of the joints partake of this structural weak- 
ness, and by the effects of weight and pressure become stretched 
irregularly. In this way knock-knee results, or the foot turns 
out at the ankle, the arch of the instep weakens and sinks, and 
the vertebral column bends backward or to the sides. The 



■■■MHM 



218 THE MEDICAL DISEASES OF CHILDHOOD 

muscles also are weak and flabby, and their bundles and markings 
look indistinct and blurred. The subcutaneous fat is commonly 
increased, so much so as to suggest the process of fatty degenera- 
tion ; this tissue is easily affected and easily dispelled, so that in 
the presence of any wasting condition it melts away and the 
patient rapidly becomes emaciated. This asthenic tendency per- 
vades the whole body, so that specialized tissues show the effects 
of the strain in ways that are characteristic of their location and 
function. Thus the mucous membrane, all through the gastro- 
intestinal and respiratory tracks, becomes readily irritated and 
inflamed, the effects of which vary according to the nature of 
existing excitant. The lungs are materially influenced by the 
beading and malformations of the ribs ; the weakness of these 
bones, aided by atmospheric pressure and the pull of the dia- 
phragm, causes a depression of the chest wall along the diaphrag- 
matic line (Harrison's Groove). Under the enlarged costo-carti- 
laginous joints and this " rachitic girdle " the pulmonary tissue 
may be collapsed. In addition, the obstructive action of con- 
comitant disease, such as pertussis or bronchitis, may enlarge the 
collapsed area to a dangerous degree. In the presence of this 
collapse there will be a compensatory emphysema, especially in 
the front of the lungs where the weak confining structures permit 
dilatation. 

The changes in the lung accompany alterations in the struc- 
ture and position of the heart. The muscle fibres are blurred 
and indistinct, with the natural result of weakened functional 
activity. Also the organ is pushed downward and outward, so 
that the apex beat is seen farther toward the mammillary line 
than is normal. The liver, spleen, and lymphatic glands may, 
one or all, be enlarged as the result of simple hyperplasia due to 
weak pulmonary and cardiac activity. But only in unusual cases 
do the changes involve a noticeable interstitial change. The 
spleen, especially, may be enlarged on account of the anaemia that 
is so commonly present. The red blood cells are then decreased 
in number, and their size, shape, and vitality are more or less 
impaired. Coincidently the haemoglobin is decreased and the 
number of leucocytes is increased. 

The nerve tissues are doubtless affected ; but in what the 
changes consist has not been thoroughly ascertained. 

Symptoms. — In mild cases all that one can see is a dispo- 



DISEASES OF MALNUTRITION 219 

sition to sweating, especially about the head, during feeding and 
sleeping. The hair on the back of the head is worn off, so that 
this part of the scalp may be bald while others are fully covered. 
The child may be fat and round, but his flesh is flabby, his 
vitality is deficient, and he is liable to have a succession of 
sicknesses. He develops slowly, he walks and talks later than 
one expects. The epiphyses are somewhat enlarged, especially 
at the wrists, elbows, and ankles. On slight provocation he 
contracts diseases of the lungs and gastrointestinal track, and 
whatever sicknesses visit him run a more serious and protracted 
course than in robust patients. Unless active disease is present, 
the temperature is commonly subnormal. 

In a severe case of rickets the symptoms are very much more 
distinctive. The head is large, square, distorted by prominent 
bosses on the frontal, occipital, and occasionally the parietal bones. 
In other parts, especially along the margins, the bone is notice- 
ably thinned, sufficiently so to bend under pressure. The cranio- 
tabes is on the inner, while the bosses are on the outer plate of 
the skull. The fontanelle remains open much longer than is 
usual, and may at the same time be larger than the ordinary 
size. The sutures remain unclosed for a comparatively long 
time, and have along their margins a series of roughnesses. The 
general appearance of the head is one of asymmetry, of incom- 
pleteness, of bad modelling. The teeth appear later than usual, 
or if they are not slow in their development they are commonly 
friable, weak, and easily decayed. The long bones are enlarged 
at the epiphysis, particularly the lower, and to a less extent along 
the shafts. The tibia, fibula, radius, and ulna are more fre- 
quently attacked than the femur and the humerus. On account 
of the enlarged epiphyses and the relaxation of the ligaments, the 
various deformities of the joints ensue. With these deformities 
there is commonly some twisting or bending of the shafts of the 
bones in one or other direction. 

One of the earliest and most constant changes is the enlarge- 
ment of the ribs at their junction with their cartilages. In 
marked cases the increase in size is very noticeable, and the pro- 
tuberances, on account of their resemblance to a string of beads, 
have been called the rachitic rosary. Although they are plainly 
marked on the anterior aspect, they are regularly larger on the 
posterior surface of the ribs. Both the bones and joints are 



H^HMH^^^H 



220 THE MEDICAL DISEASES OF CHILDHOOD 

softer than the normal. Pressure exerted on these structures 
necessarily produces an alteration in their form. This is most 
noticeable in the furrow, produced in this way, which runs from 
the lower part of the sternum downwards and across the chest 
to the posterior axillary line, following the attachment of the 
diaphragm. Since the chest wall is held down at this line, the 
parts of the ribs below it are gradually forced outward by strong 
respiratory efforts. Another furrow is formed in a similar way 
along the costo-cartilaginous junctions, thus running parallel with 
the " rosary." Another deformity, the so-called chicken breast, 
is the narrowing of the anterior chest and projection of the ster- 
num which is likewise due to atmospheric and intra-thoracic press- 
ure and the strain of muscular activity. While these changes 
are going on in the ribs, the clavicles are likewise becoming en- 
larged, irregular, and weak ; and in some cases the scapulas follow 
suit and assume the curve of the rounded back. All the long 
bones mentioned above may on account of their softness and 
friability be subject to partial or complete fractures, most of 
which are of the green-stick variety. 

The relaxation of the ligaments is plainly evident in the back, 
which thereby becomes rounded. In addition, the vertebral column 
may assume a lateral curvature, and at the same time a kyphosis 
of the lower half exists which throws the upper half into a com- 
pensatory forward curve. While the child is very young these 
accentuations may be temporarily abolished by traction, but if 
they continue until the bone softness disappears, they are apt to 
remain unchanged. The bones of the pelvis are thickened and 
softened ; and when the child begins to walk, the weight of the 
body from above pressing down upon the resisting femora forces 
the sacrum and the related parts forwards and makes the pelvic 
space shallower than it normally would be. These and all other 
bones which are touched by the rachitic changes do not attain 
their full size. 

Weakness is not confined to the bones, but pervades the whole 
body. Nowheres is it more noticeable than in the muscles. 
For this reason rachitic children are not able to sit up alone, to 
stand, walk, or obtain proper muscular coordination. This weak- 
ness varies widely in different cases : one child may on account of 
it be regarded merely as delicate, another may not have sufficient 
strength to move a limb, and lies in bed as if partly or wholly 



DISEASES OF MALNUTRITION 221 

paralyzed. The asthenia may have far reaching effects, may 
diminish peristalsis of the stomach and intestines, may permit 
gastric and intestinal dilatation, and is the cause of the character- 
istic pot-belly of rachitis. The ordinary effects of gastric and 
intestinal fermentation, of functional disorders of the stomach, 
of constipation alternating at times with diarrhoea, may be ex- 
pected. The mucous membranes in their irritated condition are 
prepared to act as a fertile culture ground for severe and organic 
diseases. 

A somewhat similar condition exists in the lungs, which is 
exaggerated by the deficient pulmonary activity. There is con- 
stant danger of inflammation of the larynx, naso-pharynx, and 
bronchi. Upon these the most serious diseases of the lung may 
be built up, which in the debilitated condition of the patient have 
a gloomy outlook. 

The nervous symptoms are not absolutely definite, but they 
are undoubted. The sweating of the head and body, which may 
be the starting point of many congestive attacks, is in all likeli- 
hood due to some unknown defect in nerve activity. The ease 
with which rachitic children have convulsions may be caused by 
abnormal reflex irritability and imperfect cerebral control ; with 
disorders of the gastrointestinal track as a beginning these 
factors could certainly produce the characteristic condition as 
one usually sees it. In the same obscure way one may trace the 
cause of laryngismus stridulus, so often seen in these patients. 
It is impossible to account for its frequent occurrence. A reason- 
able conjecture may include a series of effects starting with an 
atonic condition of the gastrointestinal track, the fermentation 
of food, the absorption of products of fermentation and putrefac- 
tion, and a final stage of low intoxication, one of whose expres- 
sions is a spasmodic condition of the larynx. The tonic spasm of 
the hands and feet, so often associated with laryngismus stridulus 
in rickety children, may be caused in the same way. The tetanic 
condition is noteworthy : the thumbs begin to turn in toward 
the palm, and the nail presses into the surface of the third finger. 
The fingers are squeezed together in the form of a cone, and the 
whole hand is flexed from the wrist. The feet are similarly con- 
tracted, and in both hands and feet, if the spasm is very marked, 
the violent contraction of the muscles may shut off the return 
circulation and make the dorsal surface cedematous and purplish. 



■M 



222 THE MEDICAL DISEASES OF CHILDHOOD 

Some variations from the ordinary occurrence of rickets are 
handed on from one writer to another as a sort of literary bequest. 
One of these is the so-called congenital rickets which has been 
seen in England and Austria much oftener than in America. 
Another is late rickets, occurring in children of five, six, or more 
years of age. Although in my clinic I see a fairly large number 
of rachitic children, nevertheless I have never met a true case of 
either of these variations. 

Treatment. — The preventive treatment should be an impor- 
tant matter of thought in families where a pregnant mother is in 
a debilitated condition, also where an older child has suffered 
from rachitis. By proper arrangement of the patient's food the 
disease will not be allowed to develop. 

This same fact is at the bottom of the treatment after the 
disease has once obtained a foothold. Since sugars and starches 
in excessive quantities are, in large part, responsible for the 
rachitic condition, they should as far as possible be replaced by 
nitrogenous foods plus easily digested fats. Milk and cream 
properly combined, as described in the section on infant feed- 
ing, are to be the food for infants. Older children may in addi- 
tion have eggs, beef and mutton, meat gravies, fresh fruits, and 
cod-liver oil. These foods must be given in their most easily 
digestible forms; and the various accidental disorders of the 
gastro-intestinal canal will have to be taken into account before 
a hard and fast dietary may be prescribed. This is especially 
true in regard to the administration of cod-liver oil. The value 
of a food depends not so much upon its intrinsic worth as upon 
the ability of the patient to digest and assimilate it. And 
although the oil may in itself be an excellent ingredient in the 
child's diet, nevertheless until he can absorb it there will be 
more harm than benefit obtained from its use. Therefore, if one 
is sure that the patient's intestines have a sufficiently vigorous 
action, small doses (1 gramme — 16 drops — for a child of one 
year) may be given two or three times a day. As the patient 
proves his ability to digest the oil, the size of the dose may be 
increased. 

An equally important factor is the regulation of the general 
life. The child must be kept in the air as much as possible ; if a 
trip to the country or seashore can be provided, the cure will be 
much more rapid and thorough. Even if the weather is not ideal, 



DISEASES OF MALNUTRITION 223 

the child should nevertheless be kept out of doors for at least a 
part of every day ; for there is less danger of coughs and colds in 
the open air than in overheated, underheated, or poorly venti- 
lated rooms. The same general idea applies to the sleeping 
room. Care should be taken that its supply of fresh air is suffi- 
cient, and that the cubic area is enough for the child's needs. 

Daily baths should be the rule. For infants the ordinary 
tepid bath is best, and may be followed by a brisk rubbing with 
alcohol. Children who are able to support themselves may be 
stood in a tub containing a few inches of warm water, sufficient 
to cover the feet. Cold water should then be rapidly thrown 
over the body ; the child may be dried and rubbed smartly with 
alcohol. With these weak children one should take care to secure 
a good reaction after the bath, on penalty of harming more than 
helping them. The clothing should be light but warm ; and all 
through the year woollen underwear may be used, the only differ- 
ence required by change of seasons being one of weight. 

Concurrent disorders must be treated according to their several 
symptoms. Deformities of bones in their very early stages require 
no treatment outside of massage, and if the general treatment is 
vigorously pursued, the affected parts will soon regain their nor- 
mal form. Since the natural tendency of the disease is toward 
eventual recovery, special measures for the cure of minor deform- 
ities are not often necessary. In extreme cases of deformity of 
the extremities it may be necessary to keep the patient in bed in 
order to prevent use of the arms and legs. Curvatures of the 
spine may be helped by splints, plaster jackets, passive motion, 
and postural treatment. The child should lie upon a hard flat 
mattress with the whole body in one plane. 

A number of drugs have been recommended for this disease, 
among which phosphorus occupies an important place. The value 
of this drug is doubtful, and on the whole, after a fair trial of it, I 
believe that one can get along as well without as with it. Its 
capability of irritating the stomach and intestines is large, and great 
care must be observed in its use. The ordinary dose is from 0.0003 
to 0.0006 gramme (2-00 to ttTo £ r O dissolved in olive oil. Other 
drugs that are much used are the lime salts, such as the hypophos- 
phite or the lactophosphate. Their use began with the theory 
that since calcium salts were deficient in the bones, a cure might 
be obtained by supplying them through the stomach. This 



224 THE MEDICAL DISEASES OF CHILDHOOD 

theory is not necessarily founded upon truth ; and while these salts 
may have a tonic value, it is no greater than and possibly not as 
great as that of iron and strychnine. These with proper food and 
general care will be sufficient for practically all cases. Accessory 
symptoms, such as nervous disorders or sweating, w T ill, as the cure 
progresses, subside without additional treatment. 

Prognosis. — As has been stated, the progress of the disease 
is toward recovery. In the presence of proper treatment the 
patients, unless some intercurrent disease sets in, should regularly 
recover. Even without treatment, if the character of the disorder 
is not especially severe, the changes in the bones gradually 
resolve themselves, and these parts may even become harder than 
they are in normal children. Marked deformities, such as knock- 
knee and bow-legs, may require orthopaedic treatment. Under 
such circumstances a radical operation is to be preferred to the 
slow treatment by pressure splints ; the operation should not be 
performed until the child is old enough to bear it without danger- 
ous shock. 

The main danger of rickets lies in the general weakness which 
characterizes it, and in the presence of which diseases of all kinds 
are easily contracted and feebly resisted. Of these the gastro- 
intestinal complaints are most to be feared in the summer and 
pulmonary in the winter. 

Differential Diagnosis. — Rickets is not often confused with 
other disorders ; for the enlarged bones, the profuse sweating, the 
square head, large fontanelles, lax joints, pot-belly, delayed or 
poor teeth, the slow development, and general weakness are char- 
acteristic enough to point unerringly to the correct diagnosis. 
Occasionally a very marked case of muscular weakness may sug- 
gest from the utter helplessness an anterior poliomyelitis with 
paraplegia. The previous histories of the two diseases are quite 
dissimilar ; the rickets would have its other symptoms, and the 
infantile paralysis would give its own electrical reactions. Cre- 
tinism may, on account of the partial growth, the open fontanelles, 
and delayed eruption of teeth, be thought of ; but the other 
symptoms of rickets are not present. Syphilis and scorbutus are 
mentioned as confusing agents ; but the pictures which they pre- 
sent are not enough like that of rickets to suggest more than 
temporary doubt for the physician who is fairly familiar with all 
three. 



DISEASES OF MALNUTRITION 225 

Infantile Scurvy (Barlow's Disease) 

When adults are deprived for a considerable time of fresh food 
their liability to contract scurvy is well known. The same possi- 
bility exists in children. The one has been recognized for a long 
time ; the other, strangely enough, a comparatively short time. 
In the light of present knowledge it seems strange that this 
important fact could so long have been overlooked. It is only 
since 1873, when Ingelev first suggested the possibility of infan- 
tile scurvy, that attention has been drawn to the disease ; and 
since 1878, when Cheadle published in the Lancet the diagnosis 
and records of three cases, we have become comparatively familiar 
with such cases. In America these cases are now frequently 
recognized. 

The cause is regularly seen to consist in the continued with- 
holding of fresh food, principally milk. Since the diet of chil- 
dren, other than infants, is more or less general, the disease is 
practically confined to the first year or year and a half of life ; for 
during this time the exclusive use of dried, farinaceous, and pro- 
prietary foods is most common. Children who are brought up on 
condensed milk and possibly sterilized milk are liable to this dis- 
order. Since the use of proprietary foods is widespread among 
the rich as well as the poor, scurvy is found in both classes. 
Indeed, a strict division of the cases will show a greater propor- 
tion among the rich, whose children are apt to suffer from too 
much care, or rather from too much unwise care. Such people 
are apt to believe that the expensive food is the best food, and 
therefore restrict their children's diet to what seems to them the 
best. Poverty produces rickets; wealth, unwisely used, makes 
scurvy. 

Lesions. — The main changes consist in extravasations of blood 
into the periosteum, bones, skin, subcutaneous and muscular tis- 
sues. The cause of this is doubtless some deterioration in the 
blood, whereby the integrity of the vascular tissues is impaired. 
It has been supposed that a decreased alkalinity is at the bottom 
of this deterioration. Such a theory is good as far as it goes, but 
it is not by any means a final explanation of the phenomena of 
the disease. The extravasations are oftenest seen in the legs, the 
vascular periosteum of the femur and tibia being the most com- 
monly affected part. Other bones, such as the ribs, scapula, hu- 



226 THE MEDICAL DISEASES OF CHILDHOOD 

merus, the radius, the orbit, are similarly affected. Haemorrhages 
may take place into the cavity of the long bones, and the medullary 
substance may be softened and degenerated. The muscles and 
mucous membranes, the joints, kidneys, mesenteric glands, liver, 
spleen, lungs, and pleura may likewise be the seat of extravasa- 
tions, and in the heart, liver, spleen, and kidneys there may be 
some degree of fatty degeneration. Thus we see, as a result, the 
swollen, spongy, and bleeding gums ; also the ecchymotic eyelids 
and the sensitive swellings on the extremities and about the 
joints. In the last named structures the haemorrhages may be 
considerable, and may be followed by a slow inflammatory process 
that finally destroys the tissue. The changes in the ribs may be 
followed by separation of the sternal ends from the cartilages. 

Symptoms. — ■ Scorbutic children are anaemic and poorly nour- 
ished, they may be thin or fat, and they are always weak. Atten- 
tion may first be drawn to their condition on account of an 
increasing physical tenderness, which is noticed on washing, 
dressing, or handling the child. He not only becomes quiet 
when untouched, but also shows a decided disposition to avoid 
all movement, and lies unusually still without changing the posi- 
tion of legs and arms. The temperature is moderately elevated, 
not often above 39° C. (102.2° F.) Examination reveals the 
presence of subperiosteal swellings, caused by haemorrhages, along 
one or more of the long bones above mentioned. If a haemorrhage 
has taken place under the periosteum of the orbit, a correspondent 
degree of proptosis may be noticed. The ordinary swelling is fusi- 
form, and gives on palpation the feeling of deep fluctuation. When 
it is near the joint, the swelling may to some degree extend on 
to the articular surface, but only in rare cases is the joint itself 
involved. The separation of the epiphysis from its shaft, as seen 
in the ribs, gives the sound and the deformity of fracture. 

When the muscles are involved, they seem soft and boggy ; 
the skin may also be involved, and become dusky and ecchymotic. 
In this way, especially when there is a subperiosteal haemorrhage 
in the orbit, the eyelids may be dark and mottled, like the famil- 
iar " black eye." A fairly constant symptom is seen in the gums, 
which gradually become heavy, swollen, soft, and purplish. The 
surface may be eroded and superficial ulcers arise. If teeth are 
present, the tissue about them swells, bleeds, and is very tender. 
There is so little firmness left in the gums that the teeth become 



DISEASES OF MALNUTRITION 227 

loose and finally fall out. The resulting cavities are apt to be 
partially filled with a purulent exudate which increases the offen- 
sive odor coming from the rest of the gums. Haemorrhages from 
mucous membranes, such as from the nose, mouth, stomach, and 
intestines, may be seen at any part of the disease ; and occasion- 
ally haeniaturia may be the first symptom to attract attention. 
The general anaemia may at times grow more profound on account 
of this hemorrhagic tendency. In all cases, however, the com- 
plexion is peculiarly anaemic and has a dull, earthy hue. 

Treatment. — The prevention of scorbutus consists in avoiding 
the exclusive use of condensed milk, dried, proprietary, farina- 
ceous, and peptonized foods. In the very rare case of a scorbutic 
nursing mother, the child should immediately be weaned. The 
active treatment does not necessarily call for the use of any drugs, 
but only for the substitution of fresh for dried foods. Fresh 
milk, modified according to the age and digestive ability of the 
child, must be the main diet for infants ; in addition, he may 
daily have a small cup of strained beef tea in which potatoes and 
carrots have been cooked. One of the best means of treatment 
at our command is potato which has been steamed and rubbed up 
with milk to the consistency of cream. A teaspoonful of this 
mixture may be put in the patient's milk three or four times a 
day. Orange juice is also beneficial. After the scorbutic symp- 
toms have passed away, the anaemia and asthenia will require 
appropriate treatment. In older children this plan of treatment 
holds equally good ; and the diet must include as much fresh food, 
both vegetable and animal, as circumstances permit. Such children 
should be treated very much in the way that an adult in similar 
pathological circumstances would be. 

Prognosis. — The outlook is usually good. Within a week or 
two after proper diet has been established, the symptoms have in 
large part disappeared. It is only in unrecognized cases or those 
in which recognition of the nature of the disease has come very 
late, that death must be expected. Some scorbutic children re- 
cover without any treatment whatever, but the majority of those 
untreated gradually become more and more anaemic, weak, and 
prostrated, until death takes place through hemorrhage, exhaus- 
tion, or intercurrent disease. 

Differential Diagnosis. — The diseases with which scurvy may 
be confounded are rickets, rheumatism, osteitis, anterior polio- 



HH 



228 THE MEDICAL DISEASES OF CHILDHOOD 

myelitis, and stomatitis. All of these have at least one symptom 
that occurs in scurvy ; but none has a group that in its entirety 
closely resembles that of this condition. A child that exhibits 
subperiosteal swellings which are sensitive to the touch, spongy 
and swollen gums, hemorrhages from the mucous membranes, and 
marked anasmia, is certainly scorbutic ; and no other disease pre- 
sents a similar combination of signs. In rheumatism the lesions 
are in the joints ; in scurvy they are almost always along the 
shafts of the bones. The pain on movement may keep one or 
more limbs abnormally still, and this has been mistaken for in- 
fantile paralysis. But as this is the only symptom in which the 
two diseases coincide, the resemblance should not be very mislead- 
ing. Hematuria has been rapidly diagnosticated as nephritis, and 
the scorbutic gums have been treated as an isolated condition ; 
but these mistakes are doubtless due to carelessness rather than 
lack of knowledge. In the very large majority of cases there 
should be no difficulty in naming the disease aright. 



CHAPTER XIV 
DISEASES OF THE NOSE AND THROAT 

Acute Rhinitis 

One of the commonest ills of children is an acute rhinitis, 
commonly called " coryza," or head cold. In almost all cases it 
is regarded as a trivial matter. In the adult it is rarely impor- 
tant, but in children and especially in very young children its 
possibilities for harm are much greater. When one calls to mind 
the peculiarities and sensitiveness of the infant naso-pharynx, 
one can at a glance see how easily an inflammation of its mu- 
cous membrane may begin, and why it is able to entail serious 
results. In these very young patients one should look upon 
every rhinitis, no matter how slight it may be, as a probable 
starting-point of a bronchitis. Leaving out of consideration 
every other harmful contingency, this fact in itself is enough to 
dignify the disease to a place of some importance. 

Causes. — The best known cause is exposure to unfavorable 
atmospheric conditions. Nevertheless, in all likelihood, there 
must be some antecedent cause, such as a micro-organism, or an 
atonic general condition, or both. Other things being equal, the 
more poorly nourished the child, the greater the liability to this 
disease. And the communicability of it is demonstrated every 
day in our ordinary lives. 

Lesions. — The pathological changes are characteristic and 
plainly marked. The mucous membrane of the nose and naso- 
pharynx is swollen and congested. There is a diapedesis of red 
blood-cells, an emigration of white blood-cells, and a transudation 
of serum. In the severer cases there may be an exfoliation of 
epithelium with possible erosions. 

Symptoms. — At first the child is apt to sneeze frequently, 
the eyes are more or less suffused, and the nasal discharge is 
prominent. This discharge is thin and acrid, but as the disease 
develops it becomes more purulent. On account of its irritating 

229 



■■ 



230 THE MEDICAL DISEASES OF CHILDHOOD 

character it is able to bring about an irritation of the skin of the 
upper lip and even the neighboring portions of the face. On 
account of the swelling of the mucous membrane and the presence 
of the discharge, the nose may become more or less stopped up, 
thus producing the natural sequence of mouth-breathing, impaired 
sleep, and, in infants, defective ability to nurse. There may be a 
slight elevation of temperature, loss of appetite, general depres- 
sion, and irritability. In the same way that the lower portions 
of the respiratory system may, by an extension of the inflamma- 
tion, be attacked, so may the lesions be communicated to the 
Eustachian tube and thence to the middle ear. The glands in 
the neighboring regions are irritated and swollen. 

Treatment. — It is a good plan to institute treatment by 
clearing the intestinal track, preferably by divided doses (0.006 
gm. — -^ gr.) of calomel followed by a mild cathartic. Warm 
baths are useful, as they relieve the general depression and help 
to resolve the local congestion. The interior of the nose should 
be frequently sprayed with an alkaline solution, or a solution 
of boric acid, while a spray of an oily material to sooth the 
inflamed area may be next applied. The end of the nose and 
the whole upper lip should be covered with vaseline as a pro- 
tective against the acrid discharge. The food should be carefully 
regulated, and as soon as possible the child should be sent into 
the air for exercise. To guard against a recurrence of the 
attack, the patient's general condition should be improved as 
much as possible by regular exercise, bracing baths, and tonics. 

Prognosis. — The disease lasts for a few days only, and the 
outlook is uniformly good. It is necessary to keep in mind 
both the weakened condition which is apt to precede the rhinitis, 
and the further weakening which must follow it. 

Chronic Rhinitis 

Causes. — Repeated attacks of acute rhinitis are commonly 
sufficient to determine a chronic inflammatory condition. In 
the face of improper climatic conditions, weakened nutrition, 
and lack of remedial care, this condition may lead to effects 
which, if not quite permanent, are hard to remove. Also the 
presence and the continued irritation of adenoid fungations are 
equally capable of producing a like result; again, the rarer 



DISEASES OF THE NOSE AND THROAT 231 

occurrence of nasal polypi may cause much the same state of 
affairs, although not so regularly as the other factors mentioned. 

Lesions. — The pathological changes are the natural extension 
of those found in the acute form. But the mucous membrane 
is much thickened and has a tendency to the infiltration of 
connective tissue. In some rare cases the necrosis of tissue is 
marked, and the stroma is infiltrated with fibrin, which holds 
in its meshes many pus cells. As a result the discharge is 
purulent, and the surface is so vitally affected in small areas 
that ulcers of various size result. This constitutes the so-called 
purulent form of chronic rhinitis. In the course of time the 
ulcers heal and the space is filled with granulation tissue ; here 
the growth of connective tissue may start, which, infiltrating 
the surface in all directions, produces contractions and deviations 
from the normal histology. The glands are encroached upon 
and gradually destroyed. The discharge, mixed with fibrin and 
pus, adheres to the surface, decomposes, and emits a most dis- 
agreeable odor. This is the so-called atrophic form of chronic 
rhinitis, formerly known by the general name of ozsena. 

Symptoms. — The symptoms consist in a more or less constant 
discharge, especially on exacerbations, the formation of crusts, 
interference with the sense of smell, deviations from the normal 
shape of the nose internally or externally, depreciation of the 
general health, and a marked tendency toward the acquirement 
of laryngeal, bronchial, and pulmonary diseases. In the purulent 
form the fetid odor is plainly noticeable. 

Treatment. — The cure of these conditions requires much 
care and time. One should, as a matter of the first importance, 
seek by every possible means, to improve the general health. 
Without this I doubt whether a cure is possible. Some obstinate 
cases require removal to a favorable climate. Where abnormal 
antecedent causes, such as new growths, exist, they must first 
of all be removed. The mucous membrane must be frequently 
douched and cleansed, and for this purpose alkaline and anti- 
septic solutions, such as Seller's, are required. The thickened 
mucous membrane may require cauterization, deviations of the 
septum may need rectification, and, in short, one should endeavor 
to remove or abate the pathological conditions as one finds them 
in individual cases. Children differ so much, one from the other, 
in the manifestations of this disease, that it is undesirable in a 



232 THE MEDICAL DISEASES OF CHILDHOOD 

general treatise to go into all the possible peculiarities of occur- 
rence and treatment. 

Prognosis. — The outlook is fairly good, certainly better than 
in adults, if parents are able and willing to respond to all the 
necessary demands upon them. They should be informed con- 
cerning the protracted nature of the disease and the necessity 
of devoting to its cure considerable attention, for the gravity 
of the possible consequences is worthy of much respect. 

Epistaxis 

Causes. — A frequent and usually unimportant complaint of 
childhood is bleeding from the nose. It usually follows some 
trivial cause, such as picking the nose, insertion of foreign bodies, 
blows, or falls. A weakened general condition produces a greater 
liability to this disorder, and an abnormal state of the mucous 
membrane, as in a chronic rhinitis, is a further provocative. 
Bleeding from the nose happens with some acute fevers as well 
as constitutional diseases ; but under such circumstances its 
occurrence is not necessarily regular. In atonic conditions, 
such as anemia and scurvy, it is often seen, and its connection 
in a grave form with haemophilia is rare but startling. 

Symptoms. — Outside of the hemorrhage, it has almost no 
symptoms. In the ordinary slight forms it is unimportant ; in 
the hemorrhagic diathesis and allied conditions it may be very 
serious, even fatal. 

Treatment. — In most cases the hemorrhage will cease spon- 
taneously. In others it will be necessary to plug the nostril, 
and while one is about it one should make the plug fairly tight. 
This plug should be secured by a string for ease in removal. 
When the bleeding-point is far back, it may be necessary to place 
the plug in position by passing a soft rubber catheter, to the end 
of which the cotton is attached, through the nose into the mouth. 
If the plug is soaked with a four per cent solution of antipyrin, 
its styptic effects will be increased. In recurrent cases one 
should locate the bleeding-point and cauterize it. 

In any but trivial cases it is advisable to improve the patient's 
general health by hygienic measures, diet, and tonics. 



DISEASES OF THE NOSE AND THROAT 233 

Nasal Polypi 

The presence of polypi in the nose is very apt to be over- 
looked, especially by the general practitioner who has not the 
opportunity of full acquaintance with them. Although infants 
are not exempt from them, the growths are most apt to occur in 
the middle and later periods of childhood. Outside of the symp- 
toms of chronic rhinitis which they entail, there are not many 
diagnostic features which inevitably draw the observer's attention 




Fig. 33. — Polypus of Nasal Mucous Membrane. X 320. 

to them. In part this is due to the difficulty which children have 
in translating subjective sensations ; for such sensations are a part 
of the symptomatology of this disorder. 

The growth, either fibrous or mucous, hangs from the middle 
turbinate bone by a pedicle. It varies in size at different times, 
becoming larger with irritating atmospheric and local conditions 
and smaller when these irritants are removed. Attention is drawn 
to them in the examination which follows disorders of the nose, 
larynx, and ear, complaints of headache, partial lack of smell, 
restless sleep, headache, and malnutrition. The only way in 



234 THE MEDICAL DISEASES OF CHILDHOOD 

which one can be sure of the presence of nasal polypi is to see 
them on examination. 

The treatment consists in twisting them off by a forceps or 
removing them with a snare. 



Adenoid Vegetations of the Pharyngeal Vault 

In comparison to the disabilities entailed, there is none of the 
diseases of children outside of the fatal ones which is more im- 
portant than hypertrophy of the pharyngeal tonsil. Moreover, 
there is none that originates more easily, has more widely distrib- 
uted effects, and is more easily cured. All in all, it is a most 
interesting condition, especially in view of the many results, with 
the most diverse tendencies, which follow it. 

Causes. — Although no child is free from the possibility of its 
attack, poorly nourished, rachitic, and lymphatic children have a 
predisposition to it. Such a patient should always be suspected, 
until cleared by examination, of being thus afflicted. Under such 
circumstances trivial adventitious causes, such as slight rhinitis, 
inclement weather, or unimportant injuries to the nasal mucous 
membrane, are sufficient to start it into existence. It often shows 
itself after the acute fevers, especially measles. 

Lesions. — In the mucous membrane of the naso-pharynx one 
finds many characteristics of that of the pharynx. An example 
is the analogy between the two faucial tonsils and the pharyngeal 
tonsil, sometimes called the third, or Luschka's, tonsil. In health, 
this third tonsil is very small, but when hypertrophied it may 
attain so great a size that it fills up the vault. It is made up of 
lympho-mucoid follicles which are an exaggeration of simple 
normal histological elements. It may attain various shapes and 
sizes, may grow in separate masses, in grapelike branches, or 
merely as a heavy formation without definite outline. 

With this growth certain other changes frequently occur. 
These may be the pathological features of an inflammation of such 
parts as the nose, pharynx, larynx, Eustachian tube, and middle 
ear. Also on account of the impeded respiration, there may be a 
deficient oxidation of the blood with consequent low forms of 
intoxication. These obscure changes are among the most inter- 
esting and protean features of the disease. 



DISEASES OF THE NOSE AXD THROAT 235 

* 

Symptoms. — The first things of which the parents are apt to 
complain are restless sleep and some degree of impeded develop- 
ment. Questioning will usually bring out the fact that the child 
snores in his sleep, sleeps with open mouth, is easily subject to 
rhinitis, laryngitis, and bronchitis, is poorly nourished, and is apt 
to be peevish and finical. In marked cases, especially those of 
long standing, deformities of the face and chest may occur. The 
bridge of the nose may be high and thick, the palatal arch high 
and narrow, the upper jaw contracted so that the teeth project, 
crowd, and override one another. 

After having seen a few characteristic cases, one ought to be 
able in many instances to make a diagnosis merely from the 
child's appearance and expression. The mouth remains open, the 
lips are thick and heavy, the eyes are dull and stupid. Examina- 
tion of the chest will show a greater or less degree of flat-, barrel-, 
or pigeon-breast deformity. Whether one or the other of these 
conditions will follow depends upon the existence of such compli- 
cations as bronchitis, rachitis, and the different degrees of malnu- 
trition. Frequently one sees various forms of pharyngitis, rhinitis, 
and otitis, caused by adenoid vegetations, running a most obstinate 
and protracted course, defying all curative measures until the 
growths are removed. In the same way, a chronic bronchitis, 
with a similar aetiology, may give rise to an emphysema which 
in its turn may start an interstitial pneumonia. Often enough 
one may notice that certain children, who suffer from adenoid 
vegetations, frequently and easily fall into congestive pulmonary 
conditions which render them a fertile culture-ground for specific 
lung diseases. 

Another interesting feature of the symptomatology is the sub- 
jective impressions induced by the abnormal conditions from 
which these children suffer. For instance, take the disorders 
which attack the ear, and their possibilities. These follow from 
the occlusions of the Eustachian tube by the growth, which thereby 
prevents the normal ventilation, and dams up the natural secre- 
tion. As a result, the tube becomes congested and inflamed ; the 
middle ear becomes similarly influenced, with a natural accom- 
paniment of subjective noises. These the child translates in vari- 
ous fantastic ways, thus unwittingly bewildering and deceiving 
his parents and attendants. Such incidents can color his whole 
life with a hue of unreality, involving all his sense-impressions, 



236 THE MEDICAL DISEASES OF CHILDHOOD 

and ways of thought. Attacks of asthma or hay fever may like- 
wise follow in this obscure train of complicating symptoms. 

Treatment. — There is one sure way of dealing with adenoid 
vegetations, and that is their radical removal. This should be 
done under chloroform anaesthesia by means of a post-nasal forceps 
or curette. The mouth may be held open by a gag, and the oper- 
ation should be rapidly executed. While in most cases the 
haemorrhage is trivial, it may occasionally be serious ; and I have 
had two cases in which it was necessary to plug the posterior 
nares. In making the preliminary examination the physician can 
avoid having his finger bitten if he will press a fold of the child's 
cheek, with a finger of his free hand, between the open jaws. 
This is easily accomplished, can do no harm to the patient, and 
gives the examiner a full opportunity to acquire all necessary 
information. 

For a few days after the operation it is advisable to spray or 
douche the cavity at least four times daily with an alkaline anti- 
septic solution. The child should be confined to bed for two 
days, and not permitted to go into the open air for two days more. 
The medical treatment usually consists in the administration of a 
tonic such as one of the organic preparations of iron. 

Prognosis. — The outlook is uniformly favorable except in 
very marked cases of long standing where permanent deformities 
may exist before the operation. These cases, however, are excep- 
tionable. 

Acute Simple Tonsillitis 

After infancy children often suffer from various degrees of 
inflammation of the tonsils ; but during the early months of life 
the disorder is more rarely seen, possibly because the child has 
a less active life with fewer opportunities of infection from food 
and foreign bodies put into the mouth, as well as fewer occasions 
of exposure to unfavorable climatic conditions. In the presence 
of irritation of the superficial tissue, the tonsils easily become 
subject to congestive changes as well as invasion by bacteria. 
One attack makes the child more susceptible to the disorder than 
he originally was ; and in the spring, more than at any other 
season, he is apt to contract this acute infection. Usually there 
is apt to be a generally lowered nutrition ; and such a condi- 
tion not only permits an easier entrance of the disease, but 



DISEASES OF THE NOSE AXD THROAT 



237 



also makes the attack severer than it otherwise would be. 
Other diseases, such as scarlet fever, measles, diphtheria, and 
sometimes lobar pneumonia, bring about a general inflamma- 
tion of the mucous membrane of the throat, in which the tonsils 
are included. 

Lesions. — The changes which take place include congestion 
of the vessels, an exudation of serum with some fibrin, an emi- 
gration of red and white blood-cells. In this exudate large 
numbers of bacteria may be found. 




Fig. SI. —Acute Tonsillitis. X 



Symptoms. — The symptoms are of all degrees, from barely 
noticeable pain to severe prostration. The tonsils are red and 
swollen, and the cervical glands may be somewhat enlarged. The 
temperature may range from normal to 39.5° C. (103.5° F.). 
There may be sufficient soreness in the neck to make deglutition 
unpleasant or difficult. 

Treatment. — The treatment is simple ; in fact, the simpler 
one makes it, the more comfortable will the child be. First of 
all, the gastro-intestinal track should be thoroughl}' emptied. 
The throat should be regularly and frequently sprayed with an 



238 THE MEDICAL DISEASES OF CHILDHOOD 

alkaline, antiseptic solution. In marked cases the application 
of ice bags to the neck may give relief. For internal medication 
remedies which will promote excretion, such as the compound 
mixture of rhubarb and soda, with small doses of nux vomica, 
will help the patient make a quicker and better recovery. 

Prognosis. — The outlook is good. One should, however, 
keep in mind that every attack of tonsillitis makes a chronic 
inflammation so much the more possible; and also that the 
inflamed mucous membrane easily becomes the seat of further 
disease. 

Acute Follicular Tonsillitis 

This is an acute, contagious, self -limited disease, whose symp- 
toms are out of all proportion to its real danger. While the 
disease is not limited to children, it attacks them more fre- 
quently than adults ; on the other hand, they generally seem to 
suffer less from the prostrating efforts than mature patients. This 
may be readily demonstrated in families where one person after 
another is attacked. Certain individuals seem to be predisposed 
to it, and those of a rheumatic tendency are included in such a 
category. Any simple acute or chronic inflammation of the 
tonsillar mucous membrane makes an attack of the follicular 
disease more easily possible than healthy tissue does. No specific 
germ has been found in the exudate on the tonsils, although 
large numbers of the ordinary streptococci and staphylococci of 
purulent processes may regularly be distinguished. 

Lesions. — Although the whole tonsil is inflamed, nevertheless 
the process is primarily localized in the crypts. These crypts 
become blocked up with masses of serum, fibrin, pus, and blood 
cells, ephithelial detritus, bacteria, and particles of food. In first 
attacks the lymphoid tissue for the most part is involved and 
swollen. As the attacks are repeated, there is a progressively 
greater amount of fibrous tissue present and involved in the 
inflammation. According to the intensity of the pathological 
process and the weakened resistance of the patient, the inflamma- 
tion spreads over the adjacent mucous membrane. 

Symptoms. — The first sign that attracts the parents' atten- 
tion is the marked prostration. The child seems to be seriously 
sick, the temperature runs high, often reaching 40.5° C. (105° F.) 
and occasionally higher. The pulse is rapid, the general pain is 



DISEASES OF THE NOSE AXD THROAT 239 

severe. Urinary analysis frequently shows the presence of febrile 
albuminuria, which, however, persists for no more than a short 
time. Inspection of the throat shows an inflammation of the 
tonsillar mucous membrane, which gradually fades off into the 
near-by parts. Scattered over the tonsil are the swollen follicles, 
and from some of them small plugs of exudate project. Some 
of these when close together may coalesce, forming a membrane- 
like deposite of a yellow, thick, uneven, and dull appearance. 
The cervical glands are enlarged and tender, but do not go on to 
suppuration. The purely local symptoms may be bilateral, but 
the membrane does not often go beyond the tonsils. Occasionally 
one is apt to see a fine, erythematous rash that accompanies this 
disease. It fades away after the lapse of a few hours or a day, 
and requires no especial attention. 

Treatment. — The treatment, while not specific, is satisfactor}-. 
Sufficient calomel or a saline cathartic should be given to empty 
the stomach and intestines. Ice bags should be placed on the 
sides of the neck opposite the tonsils, and the throat may be 
frequently and thoroughly sprayed with a solution of hydrogen 
peroxide and boracic acid. Relief can be given within a short 
time by the use of equal parts of phenacetine and salol, taken 
every two hours ; the dose of each for a child of about five years is 
gm. 0.12 (gr. ij). The food should be small in quantity and of 
an easily digestible nature. In cases of a rheumatic tendency 
one may get relief from fairly large doses of salol, salophen, or 
similar preparations. 

Prognosis. — The outlook is almost always good. In some 
few cases a peritonsillar abscess may follow the acute tonsillitis 
or one of the various other inflammations of the throat and mouth, 
which naturally find a good starting-point in the inflamed surface. 

Differential Diagnosis. — The diagnosis rests between follicular 
tonsillitis and diphtheria. The former attacks the tonsils only ; 
it appears in scattered areas, and if these coalesce, the membrane 
has a clear, whitish appearance. In diphtheria the membrane is on 
any part of the tonsils, pharynx, or larynx ; or if in the beginning 
it is confined to the tonsils, it soon spreads to the adjacent parts. 
In appearance it is yellowish, dull, and not clean looking. In 
follicular tonsillitis the fever is high, and the pain and discomfort 
marked. In diphtheria the fever is moderate or low, and the pain 
not so great. In the former the depression passes away in the 



■■■ 



240 THE MEDICAL DISEASES OF CHILDHOOD 

course of a day or day and a half ; but in the latter it lasts much 
longer, and may progressively increase until the disease ends in 
its usual manner or as the result of treatment. Finally, the mat- 
ter is definitely settled when a culture has been made, which 
shows the presence or absence of the Klebs-Loeffler bacillus. 

Chronic Inflammation and Hypertrophy of the Tonsils 

Causes. — Hypertrophied tonsils at birth are rare ; neverthe- 
less they occur. Still oftener one sees children whose tonsils are 
predisposed to inflammation and consequent enlargement. With 
such patients slight causes of irritation are sufficient to set the 
process in motion. Thus, a harsh and trying climate, a rheu- 
matic predisposition, or the lymphatic tendency is sufficient to 
produce tonsillar hypertrophy. In a few young cases, and in a 
yet larger proportion of older children, repeated attacks of acute 
inflammation of the tonsils, or even of the pharynx, make a pro- 
gressive increase in all the various elements in the gland so 
that the throat gradually becomes more and more obstructed. 
Whether the glandular or connective tissue predominates is of 
but little practical importance, with the possible exception of a 
few rare cases where the interstitial tissue is so very much in 
excess as to render possible a greater haemorrhage after ampu- 
tation. This is not a serious danger, and should not be allowed 
to prevent the operation. 

Lesions. — The pathology is not particularly interesting, and 
from it we derive no especial indications for differential treat- 
ment. Where the connective tissue is most involved, the tonsil 
is hard and gnarled ; where the glandular tissue is principally 
the seat of inflammation and hypertrophy, the tonsil is larger, 
redder, and more prolific in secretion. One usually finds varying 
degrees of mixture of these elements. 

Symptoms. — The child suffers, for the most part, from symp- 
toms of obstruction. The voice may be thick and wooden, there 
may be a chronic associated pharyngitis, rhino-pharyngitis, and 
rhinitis. The two glands may be so large as to meet, or nearly 
meet, thus interfering with respiration and the consequent oxy- 
genation of the blood. With the condition there may be an 
hypertrophy of the pharyngeal tonsil, but even if there is not, 
the symptoms may be much alike. Thus the bulging growth may 



DISEASES OF THE XOSE AND THROAT 241 

press upon or occlude the pharyngeal entrance to the Eustachian 
tube, setting up an inflammation that extends into disease of the 
middle ear. The same results of restless sleep and breathing, of 
deformity of the chest, and impaired nutrition may be present in 
both. Where the faucial tonsils are hypertrophied, one should 
always suspect the pharyngeal tonsil of being similarly involved, 
and removal of the first should not be decided upon without a 
digital examination of the naso-pharynx in order to convince 
oneself of the potential necessity of likewise clearing it out. 

Treatment. — The treatment is plain, and should not be 
obscured by palliative measures. If the tonsils are large enough 
to produce obstruction or marked irritation, they should be ampu- 
tated. While one is about it, the patient will obtain most benefit 
by leaving very little stump ; for the removal of no more than 
the cortex permits too frequently a return of the whole trouble. 
Rarely is the operation troubled by haemorrhage . If it is, in the 
vast majority of cases, it can be checked by pressing the thumb, 
which has been covered with a bandage, against the bleeding 
surface while the fingers make counter pressure from the corre- 
sponding part of the outside of the neck. Another satisfactory 
way of obtaining the same result consists in having the patient 
suck fairly large pieces of ice for a few minutes. In very rare 
cases the galvano-cautery may be needed to stop the haemorrhage ; 
but the usual experience is that the bleeding stops spontaneously. 
The throat should then be kept clean by frequent spraying or 
gargling with boracic acid. 

When one desires to remove an hypertrophied phanmgeal 
tonsil in addition to the faucial tonsils, an anaesthetic should 
always be administered. The faucial tonsils should first be 
removed. After almost all cases of tonsillotomy it is advisable 
to give tonics, and in all ways sedulously to promote the general 
nutrition. 

The outlook is good, and the operation should not be regarded 
as dangerous. 

Peritonsillar Abscess 

Children who are in poor general health, especially those who 
have been suffering with some form of throat disease, are liable 
to contract an inflammation of the cellular tissue around the 
tonsil. While the general practitioner may not have many occa- 



H 



242 THE MEDICAL DISEASES OF CHILDHOOD 

sions to treat such a condition, the specialist in charge of a large 
clinic or hospital sees a sufficient number of cases to keep fresh 
in his mind the possibility of this disease. 

There may or may not be a chill; there is always a rise of 
temperature to about 40° C. (104° F.). The pain is mostly local 
and the general prostration is not in all cases great. As the 
swelling increases the head may be held in a cramped position, 
and in unusual cases of extreme degree the acts of eating and 
drinking may be impeded ; in other cases the infiltration may 
be so great as to effect the larynx. When the abscess is fully 
formed, it may rupture spontaneously. If this happens during 
sleep, the pus may be inspired, with a fatal result. This, however, 
is unnecessary. If, after examining the throat, the peritonsillar 
tissue is seen to be swollen, and the application of an ice bag is 
without avail, one should be prepared to operate. 

Treatment. — As soon as one can detect fluctuation, the abscess 
should straightway be opened freely; it is advisable to enlarge 
the incision by passing into it a pair of forceps which then 
should be opened, thereb} 7 " materially enlarging the drainage area. 
The incision should be made outside of and above the tonsil, and 
downward. 

The treatment is not entirely surgical. The first step should 
be the thorough cleansing of the gastro-intestinal track by means 
of calomel or a saline cathartic. The food should be as easily 
assimilable as possible. During convalescence one may have to 
administer tonics, and to supervise the diet and mode of life. 
The mouth must be kept as clean as possible. 

Prognosis. — If the disease is promptly treated the outlook is 
good. The main danger arises from allowing the abscess to in- 
crease in size until the larynx is encroached upon, or until spon- 
taneous rupture occurs with the attendant danger of inspiring 
the pus. Both of these conditions may result in death. 

Uvulitis and Elongated Uvula 

As a primary disorder an inflammation of the uvula is rare : 
so much so, that when it occurs one regards it as a curiosity. 
For the most part, it comes with acute pharyngitis and rhinitis. 
The uvula is swollen, the vessels are congested, and there is a 
hypersecretion of mucus. The child has a feeling of discomfort 



DISEASES OF THE XOSE AND THROAT 243 

in the throat, as if an unnatural substance were there ; he is tor- 
mented by an irritable cough, although the lungs are quite clear. 
Especially on lying down this symptom is annoying ; and until the 
uvula resumes its normal size the patient will experience all the 
discomforts that come with irritating the surrounding parts. In 
this way attacks of laryngitis or laryngismus stridulus may be 
put in motion ; and doubtless in some cases asthma may originate 
in the same way. 

An astringent applied to the part will reduce the size : and a 
spray or gargle of an alkaline and antiseptic solution will promote 
a normal condition. In very severe cases it may be necessary to 
make many minute scarifications. In case the uvula remains too 
large, it will be necessary to remove its tip. This is easily done 
with a forceps and scissors. One should be careful not to ampu- 
tate too much. 

The uvula is sometimes congenitally elongated. It then 
causes all the irritating effects mentioned above. The treatment 
is amputation of the tip. Some cases of bifid uvula seem to have 
a natural tendency to elongation. 

Acute Phaeyxgitis 

Causes. — An inflammation of the pharynx or any part of it 
is a frequent incident in a child's life. The conditions which pre- 
dispose to and cause it are so easily contracted that the disorder 
is one of the most common with which we have to do. The 
existence of any pathological condition of the near-by parts or an 
hypertrophy of the tonsils, either faucial or pharyngeal, easily 
starts the inflammation in motion. Such a process is the more 
readily possible on account of the softness of the youthful mucous 
membrane ; its structure is weak, its blood-vessels are loosely held 
and easily become dilated and congested, its glands readily 
become hypertrophied and their characteristic action abnormal. 
Thus, even harsh changes of weather can produce enough irrita- 
tion to start an acute inflammation into active beino\ Most 

o 

assuredly is the irritation sufficient to make the mucous mem- 
brane a good culture-ground for the micro-organisms which are 
responsible for some attacks of pharyngitis. 

Lesions. — The pharynx is rarely alone in such an inflamma- 
tion ; one usually finds the process involving the mucous mem- 



■ 



244 THE MEDICAL DISEASES OF CHILDHOOD 

brane of the nose or the throat as well. This membrane is 
swollen, the vessels are congested, the glands are hypertrophied. 
At first, secretion is diminished, but shortly it becomes profuse. 
It is composed of mucus, fibrin, red and white blood-cells, and 
epithelial debris ; in follicular pharyngitis, the inflammation cen- 
tres about individual follicles, which thereby become swollen and 
prominent. 

Symptoms. — The child complains of local pain, a rise of tem- 
perature, loss of appetite, and general malaise. The lymphatic 
glands in the mouth, throat, and neck become swollen and often 
tender. In itself, acute pharyngitis is not a very important sick- 
ness ; its main interest lies in the fact that it may be one of the 
prodromata of some acute infectious diseases, such as diphtheria, 
scarlet fever, and measles. Scarlet fever even more than measles 
may thus be overlooked, for it gives a red hue to the pharynx 
that in typical cases differs materially from the dotted and irreg- 
ular appearance seen in measles. Likewise in these two exan- 
thems there is apt to be a precedent or accompanying rhinitis and 
conjunctivitis. Nevertheless, the diagnosis in acute pharyngitis 
must always be a guarded one until sufficient time has elapsed to 
settle the question of systemic involvement. 

Treatment. — The care of pharyngitis is more worthy of full 
attention than is generally thought, mainly because if untreated 
it may extend in all directions or pursue a prolonged course. 
The gastro-intestinal canal should be emptied, the diet should 
be restricted, and the nose and throat should be sprayed with 
an alkaline antiseptic solution. If the attack is in any way 
severe, the patient should be confined to bed and in every way 
exposure must be avoided. For elevation of temperature, sponge 
baths are more valuable than the antipyretic drugs. When con- 
valescence sets in, tonics may be needed. 

The prognosis is good. 

Chronic Pharyngitis 

Causes. — The chronic form of pharyngitis is not so often 
seen in children as in adults. Nevertheless, occasionally one 
meets such a condition which may have resulted as an extension 
of an acute attack, or from the constant irritation of a long uvula, 
from enlarged tonsils, hypertrophy of the pharyngeal tonsil, nasal 



DISEASES OF THE NOSE AND THROAT 



245 



polypi, and similar causes, that keep the mucous membrane in a 
state of excitement. Living in a harsh climate not only predis- 
poses to the disease, but also aggravates it. 

Lesions. — The changes are much the same as in the acute 
form ; but the mucous membrane is apt to be irregularly thick- 
ened and slightly infiltrated with new tissue. In the region of 
this new tissue the follicles are apt to be prominent. The secre- 
tion is often less copious than in the acute form, but it is thicker 
and more tenacious. 




Fig. 35. —Normal Lymph Node. X 80. 



Symptoms. — The principal symptoms are cough, some degree 
of malnutrition, impaired appetite, and disturbed sleep. In addi- 
tion there will naturally be the signs of the particular cause 
which is responsible for the pharyngitis, such as an enlarged bifid 
uvula or pharyngeal tonsil. 

Treatment. — The treatment consists primarily in getting rid 
of the cause, whatever that may be. It will be necessary, then, 
to keep the nose and throat very clean by means of an alkaline 
antiseptic solution. This may be followed in some cases by the 
application to the pharyngeal mucous membrane of a weak astrin- 
gent, such as a one per cent solution of nitrate of silver. It is 



246 THE MEDICAL DISEASES OF CHILDHOOD 

highly desirable that the child be put into good condition by what- 
ever means of tonics and regulation of daily life one may find 
necessary. 

Retropharyngeal Lymph-Adenitis 

As a result of infection young children are apt to suffer from 
an inflammation of the lymph nodes in the neck. As these nodes 
are comparatively large at birth and gradually shrink during the 
first three years, the greatest liability to disorder exists in babies 




Fig. 36. — Suppurative Lymph Node. X 70. 

of this early age. Occasionally, however, the glands persist for 
some time later, during which there is a simultaneous proneness 
to such involvement ; and I have had occasion to treat a retro- 
pharyngeal abscess in a child of nine years. 

Causes. — In almost all cases the disease begins as an infection 
by the ordinary pyogenic bacteria, such as streptococci and staphyl- 
ococci. These are most apt to find a lodgment when the child's 
nutrition is impaired and when the local condition in the throat is 
poor. Such a combination one finds after a severe rhinitis and phar- 
yngitis, the acute infectious diseases and diseases of debility. Chil- 



DISEASES OF THE NOSE AXD THROAT 247 

dren whose mouths are not kept clean contract the disease much 
more readily than those who are well cared for. In a very small 
proportion of the cases one will find the tuberculosis bacillus. 
Rarely one finds a retro-pharyngeal adenitis following caries of 
the cervical vertebrae. Here the location and extent of the infil- 
tration are somewhat different from the other cases. 

Symptoms. — The first symptoms which the parents notice are 
unwillingness to eat, pain, restlessness, and fever. The child cries 
steadily and peevishly and shows progressive degrees of prostra- 
tion. The cry is quite different in pitch and tone from what we 
hear in any other disease, so that after one has heard it a few 
times, one is able without difficulty to recognize it even without 
seeing the child. It is hard to describe this pitch and tone ; 
some call it a thin crowing sound, others describe it as quacking. 
The only way in which one can obtain a definite conception is by 
hearing it. 

Another characteristic symptom is the position in which the 
child holds his head. It is inclined somewhat to the side away 
from the inflammation and backward. These things naturally 
direct the attention to the throat, and on examination one finds a 
hard, brawny swelling which may be so large as to cause dyspha- 
gia and even dyspnoea. In some cases the interference with the 
related parts is so great as to induce hoarseness, and sometimes 
a loss of voice. Where the swelling is very marked one is often 
able to notice it externally on the side of the neck. In rare 
cases there may be as a final complicating symptom oedema of the 
glottis. 

The common name for this disorder, retro-pharyngeal abscess, 
is misleading. Not every case goes on to suppuration, and a still 
larger number when first seen contain no pus. The same rules of 
development hold good here as in other cases of inflammations of 
glands. If there is sufficient infecting material with a deficient 
power of resistance in the patient, the ultimate outcome of the 
process will be an abscess. Thus a case that at first shows no 
more than some induration and swelling may a few days later 
show the characteristic signs of an abscess, which finally, if 
neglected, may open spontaneously and allow the child to inspire 
a fatal amount of pus. 

In the retro-pharyngeal abscess which accompanies tubercular 
cervical spondylitis the course is somewhat different. The onset 



248 THE MEDICAL DISEASES OF CHILDHOOD 

is less sudden, and usually, although not always, the bone disease 
precedes the adenitis by weeks or months. The tumor, instead 
of being almost on the side, gradually makes its way to the back 
of the neck, and may even partly encircle the neck in a heavy 
ringlike mass. If left untreated, it may open spontaneously 
through the exterior of the neck or into any of the structures of 
the throat, neck, or air passages. In the last-named case the 
result is death. 

Treatment. — If the case is seen at its inception, one may 
apply ice bags externally with a view to checking the process. 
If this does not succeed directly, or if the case has been progress- 
ing for more than a day, heat should preferably be used in order 
to hasten the breaking down of the glandular tissue into an 
abscess. As soon as this takes place, there should be no delay 
in opening it. The patient's arms should be pinned to his sides 
by a large towel or blanket. An attendant, holding him on her 
lap, should grasp his body with one arm and with the other his 
forehead. The operator, depressing the patient's tongue, opens 
the abscess with a knife whose blade has been wrapped to near 
the point. If the incision has been properly made the pus will 
gush out. The patient's head should immediately be bent for- 
ward so that he may not swallow or inspire the fetid material. 
Another method, that may be advantageously used, consists in 
placing the child on his back, and allowing his head to hang over 
the edge of the operating table. One thus obtains the same 
immunity from inspiring pus. Then a closed forceps should be 
put into the wound, and gradually and steadily opened in order 
to make the aperture large enough. No further treatment, out- 
side of keeping the mouth and nose clean, is needed. The after 
treatment consists in building up the child's general condition by 
all means of tonics, diet, and exercise. 

While the operation for simple abscess can be performed by the 
general practitioner, that for the tubercular variety coming with 
cervical spondylitis should not be attempted by any one but a 
competent surgeon. Therefore the description is left to special 
works on surgery. 

Prognosis. — The outlook where the operation is done promptly 
and thoroughly is good, and the patient recovers in a few days. 
If the matter is neglected, the child's general condition may be 
so seriously depressed as to endanger life. A still more imminent 



DISEASES OF THE XOSE AXD THROAT 249 

danger is the possibility of compression of the larynx, oedema of 
the glottis, or inspiration of the pus. These things, however, 
should not happen. 

Acute Laryngitis 

Causes. — A simple laryngitis is a very common occurrence, 
both as a primary and secondary complaint, in the diseases of 
children. It exists in the widest range of severity, from a slight 
hoarseness to the gravest organic and functional changes. It may 
result from exposure, from the corrosive effects of irritating vapors, 
as an extension of an affection of any other part of the respiratory 
system, and as a complication of the acute infectious diseases. In 
its mild form it ma} T be due to violent crying and shouting. 

The characteristic pathological changes are not striking, espe- 
cially when one compares them with the severity of the symptoms, 
which in marked cases are often startling. The changes confine 
themselves for the most part to the mucous membrane ; this 
becomes hypersemic, swollen, and uneven. In proportion to the 
congestion the swelling and the dark hue of the tissue increase. 
The epithelial layer begins to desquamate, and may go on to such 
an extent that superficial ulcers of various size result. In the 
severer forms of the inflammation the deeper strata may be 
invaded ; and the climax of progressive involvement is reached 
when oedema of the glottis supervenes. An injection of the 
neighboring mucous membrane is commonly seen. As a rule, not 
much mucus is formed and less pus. 

Symptoms. — There are in this disease so many degrees of 
severity that one's conception of it must be somewhat elastic. 
Almost all cases begin lightly, commonly showing an acute 
rhinitis followed by hoarseness. The patient coughs in a dry, 
harsh, irritating manner. Disturbances of temperature, pulse, 
and respiration come with the severer attacks ; in such cases 
these disturbances may be much or little. The child in all 
likelihood will show signs of tenderness and pain in the larynx, 
the cough becomes nearly continuous, and the general prostration 
is apt to be excessive. In the older children a laryngoscopic 
examination will show much the same picture that one is accus- 
tomed to see in adults, excepting that a certain definite amount 
of pathological change gives a severer set of symptoms in the 
former, than in the latter. Dyspnoea is likely to be present 



250 THE MEDICAL DISEASES OF CHILDHOOD 

during part of the day and regularly so about midnight. As this 
increases cyanosis sets in, the attempts to breathe become more 
and more violent and shallow, until relief is obtained or the child 
becomes unconscious. 

In all affections of the larynx there seems to be a neurotic 
element which makes the liability to spasmodic contraction of the 
muscular tissue ever present. The explanation of this fact is 
hard to find ; we merely know that it exists, sometimes in such 
confusing forms as to render a distinction between the catarrhal 
and spasmodic varieties very difficult. 

Treatment. — Even mild cases should be confined to bed and 
carefully nursed ; if this is done, there will be fewer dangerous 
attacks. The intestinal track should be emptied by repeated 
doses of calomel or citrate of magnesia. Small and frequent 
amounts of antipyrin or bromoform with a stimulant, such as the 
aromatic spirits of ammonia, and dissolved in syrup of tolu, will 
give considerable ease. Inhalations of steam should be frequent ; 
in artificially heated houses it is often wise to provide a continuous 
supply of steam in the sick-room. It is necessary at all times to 
maintain the patient's general strength as much as possible. When 
the hoarseness, cough, and harsh breathing become alarming, it 
may be necessary to administer emetics. On the other hand, mild 
cases do not require this measure ; and not infrequently physi- 
cians see it adopted when unnecessary and are compelled as a 
result to treat a consequent gastritis. When the dyspnoea 
is extreme, it will be necessary to perform intubation or 
tracheotomy. 

Prognosis. — The prognosis in the ordinary cases is uniformly 
good. As the attacks become more and more severe, the danger 
increases. But even in these skilful treatment can afford so 
much relief that the outlook is in almost all cases favorable. 



Chronic Laryngitis 

Causes. — Chronic laryngitis is rare in infants, but in some- 
what older children — those of five or more years of age — it is 
fairly common. Especially is this true in the harsh climate of 
the north Atlantic coast. The disease may occur as an extension 
of an acute laryngitis that has had many remissions and exacerba- 



DISEASES OF THE NOSE AXD THROAT 251 

tions, or it originates in the irritation set up by adenoid funga- 
tions, new growths, and some specific diseases. 

Lesions. — The lesions are somewhat of the same nature as 
those in the acute form, but more deeply seated. The epithelial 
layer is irregular and wavy in contour, for the most part thick- 
ened, but with scattered areas where it is thin and wasted. The 
underlying structures are thickened, inelastic, and infiltrated with 
small, round cells. The mucous glands are hypertrophied, and 
secrete a thick discharge which is found to be mixed with some 
pus-cells. The condition is especially favorable for the growth 
of the tubercle bacillus. 

Symptoms. — The symptoms consist of hoarseness and some 
degree of aphonia, which are for passing reasons easily exagger- 
ated. On slight exposure the patient is attacked with a cough 
which one finds difficulty in quieting. At night there may be 
attacks of dyspnoea, especially at a time of an acute exacerbation 
of the pathological condition. In the older children a laryngo- 
scopical examination will show the thickened and reddened mucous 
membrane, and occasionally the presence of erosions of greater or 
less size. The general nutrition is apt to be affected so that the 
patient, even when his physical circumstances are fairly favorable, 
is weak and easily subject to acute sickness. 

Treatment. — The treatment should be aimed at removing 
whatever causes may be present, such as papilloma and adenoid 
fungations, in building up the child's nutrition by properly 
selected foods, hygienic conditions, and tonics. In older children 
one may use the same direct intra-laryngeal applications, somewhat 
diluted, that are prescribed for adults. Thus weak solutions 
of silver, ethereal solutions of iodoform, or medicated vapors, may 
be employed ; but they are of less importance than the general 
methods of treatment. When the little patient can be sent to a 
favorable and even climate, his comfort as well as health will 
have the best chance for improvement. 

Prognosis. — The outlook is not very encouraging, excepting 
in the case of those who are able to select the climate in which 
they are to live. Even such patients are liable on exposure to a 
recrudescence of the disease. 

Pseudo-membranous laryngitis is treated under the head of 
diphtheria. 



252 THE MEDICAL DISEASES OF CHILDHOOD 

Spasmodic Laryngitis 

It is a remarkable fact that very young children, who as a 
rule are not liable to noteworthy nervous impressions, are sub- 
ject to special neuroses of the larynx. In general, we may 
divide these manifestations into the two forms called spasmodic 
laryngitis and laryngismus stridulus. They are characterized 
by spasms of the larynx which temporarily interfere with the act 
of breathing. 

Causes. — The cause is unknown. Logically, there seems to 
be no more reason why the automatic respiratory function should 
be injuriously affected than other similar faculties. One can do 
no more than cite the fact that it is so modified, and then state 
certain concomitant facts. Thus we know that this neurosis 
occurs in a few years of early life, that some children have a con- 
genital tendency to it, that various forms of malnutrition, among 
which faulty digestive functions take an important place, aid its 
development. This last factor doubtless has much to do in 
determining the presence of heredity in the equation. Outside 
of these indefinite grounds, it is easy to understand how the irri- 
tation of associated abnormalties in the throat should be capable 
of setting up a spasmodic contraction of the laryngeal muscles. 
It is more apt to occur in bad than in fine weather. In spasmodic 
laryngitis there is usually some local injury or irritation, with 
which the poor general condition unites, to act as the foundation 
of the disease. But in laryngismus stridulus there is usually no 
such injury, or at all events it is of an entirely subsidiary character. 

Lesions. — The lesions are generally slight ; in some children 
they are fairly noteworthy, while in others they are barely per- 
ceptible. There may be a mild inflammation of the laryngeal 
mucous membrane, with hyperemia of the small vessels. The 
surface seems higher in color than in health, dry, and bright. 
Later on there is an increased supply of mucus, which contains 
small amounts of fibrin and pus-cells. In other cases there may 
be small erosions, the effects of injury, or the irritated condition 
brought on by disorders of neighboring parts. The direct lesions 
may not be very marked, but their influence becomes felt when it 
acts in conjunction with a poor state of the general health. 

Symptoms. — The impression which the child during an attack 
makes upon the attendants is most disquieting. He may have 



DISEASES OF THE NOSE AXD THROAT 253 

been fairly well, or have had no more than an ordinary cold, such 
as children commonly contract. In the middle of the night he 
begins suddenly to breathe with less ease. Gradually the diffi- 
culty increases, and he may wake in fright. In the severe cases 
his distress increases ; he labors wildly and unrestrainedly to 
obtain a greater amount of air. As his difficulty increases his 
efforts are frantic, the air whistles hoarsely through the con- 
tracted larynx, he becomes somewhat c} T anotic, and is plainly very 
weak. The attack in its fulness lasts only a short time and then 
rapidly leaves him. Before long he is again sleeping easily with 
nothing more than an occasional cough to testif}- to the past 
respiratory crisis. In these attacks there is often only a slight 
or even no disturbance of the temperature, the pulse is not 
markedly increased in action, and the respiration is slow. The 
greatest difficulty comes with each inspiratory effort, and at this 
time every accessoiy muscle of respiration is put on the utmost 
tension. After the attack is gone, the child may or ma)' not be 
hoarse. Commonly he may have an attack on one or more suc- 
ceeding nights, but this is not invariable. Also there are some 
cases where an acute catarrhal laryngitis or bronchitis may follow 
the original attack. 

Treatment. — As soon as the spasm shows itself the child 
should be put into a warm bath ; steam inhalations should be 
begun, and then if relief does not quickly follow, an emetic should 
be administered. Syrup of ipecac is useful in very young chil- 
dren ; older patients may take small doses of apomorphine, which 
in suitable quantities may be administered in hypodermatic injec- 
tion. To prevent further attacks antipyrin or bromoform, given 
in the evening, will be found of use. In some cases of marked 
severity it will be necessary to practise intubation. After the 
attack every effort must be directed to improving the patient's 
general condition. 

Prognosis. — The outlook is good ; for, although the condition 
seems most alarming, serious results need not be feared, especially 
if means for relief are promptly instituted. 

(Edema of the Glottis 

The mucous membrane of the glottis may, as the result of 
disease, and with or without inflammation, become infiltrated. 



254 THE MEDICAL DISEASES OF CHILDHOOD 

The condition is called oedema of the glottis. In children it is 
rare. 

Lesions. — The changes are generally situated throughout the 
upper part of the larynx and are most pronounced in the posterior 
aspect of the epiglottis and the ary-epiglottic ligaments. The 
tissue is sodden with a serous infiltration in all degrees up to 
complete closure of the larynx. When the causes are such as to 
induce an active inflammation, the appropriate changes are added 
to those mentioned above. 

Symptoms. — On account of the swelling, the lumen of the 
glottis is decreased, with a consequent difficulty in drawing air 
through it. The condition comes on suddenly, and generally 
leaves but little time for action. If one is able to practise laryn- 
goscopy, one can see the swollen and infiltrated condition of the 
parts ; the examining finger will confirm the opinion. 

Treatment. — The treatment consists in cutting and puncturing 
the mucous membrane in the hope of reducing the oedema. Its 
success is not likely to be brilliant on account of the patient's 
exhaustion. For a similar reason intubation, which is logically 
called for, is also disappointing. Tracheotomy, if performed with- 
out too much delay, may be of some use. As a rule, however, the 
child is in danger as soon as the disorder begins; any delay is 
then momentous. And the inability to obtain immediate medical 
aid, or the physician's possible hesitancy to use intubation or 
tracheotomy before the child is moribund, is often the cause of 
death. 

The prognosis is bad. 



CHAPTER XV 
DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 

Acute Bronchitis 

The inflammation of the mucous membrane of the bronchi and 
their ramifications, called bronchitis, is one of the commonest 
pathological conditions from which children suffer. There is 
hardly a child to be found who has not at some time felt the 
strain of this disorder. The physical peculiarities of a child's 
lungs invite congestion and inflammation, the conditions which 
aid in developing the disease are almost omnipresent, and as a re- 
sult the child must at some time or other fall more or less sick 
with this disease. 

Causes. — In settling upon the causes of bronchitis, one must 
keep in mind that the nose, throat, larynx, trachea, and lungs are 
closely related. An inflammation of any of these parts may ex- 
tend in the easiest manner to the bronchi ; and the degree of 
severity of the ultimate disorder need bear no direct proportion 
to that of the original trouble. A comparatively trifling rhinitis 
may extend into a severe or fatal bronchitis, most of all in chil- 
dren who are weak or exposed to unfortunate circumstances. 
Such circumstances may be atmospheric changes, rough weather, 
irritating gases. Indeed, all of these irritants may act inde- 
pendently and start an inflammation of the bronchi without any 
precedent change. Exposure of almost any sort can act as an ex- 
citing cause, even the " drooling " of young babies being at times 
sufficient. Systemic poisoning from acute infectious diseases, such 
as measles, scarlatina, pertussis, and typhoid fever, can act with 
much certainty. In addition one must take into account those 
cases which occur with intestinal diseases of an infective, putre- 
factive, and fermentative character. Sufficient attention has not 
been given to these diseases as near or remote causes of bronchitis. 
Not only do we commonly have an inflammation of the bronchial 
mucous membrane in such disorders, but also we often find Bac- 

255 



256 THE MEDICAL DISEASES OF CHILDHOOD 

terium coli commune and other pyogenic micro-organisms in the 
affected area and the exudate ; in addition observers have many 
times associated the bacillus of Lumnitze with the so-called putrid 
form of bronchitis. Finally, one should emphasize the importance 
of all weakened general conditions as predisposing causes, such as 
in rachitis, in syphilis, in the wasting diseases of adenitis, and in 
the circulatory interferences of cardiac disease. Such things, 
even if they do not act as direct causes, nevertheless make so 
favorable a physical environment for the development of bron- 
chitis that even a trivial circumstance will start the disease into 
vigorous action. 

Lesions. — The lesions in this disease vary considerably accord- 
ing to the seriousness of the attack. They may on the one hand be 
trivial, but on the other may be so severe as to produce death. 
Also the disease varies considerably according to the age of the 
patient, for infants suffer much more acutely than other chil- 
dren. In the former the large proportion of capillary tubes to the 
rest of the lung-structure makes an extension of the inflammation 
to them comparatively easy. As a result, in this class of patients 
one often finds very severe forms of the disease closely approxi- 
mating to or coinciding with broncho-pneumonia. However, in 
the majority of cases, the disease has its own individuality and 
appears distinct. 

Usually parts of both lungs are involved ; less often the inflam- 
mation limits itself to one lung, and in other cases whose serious- 
ness is in direct proportion to their youth it may spread over the 
whole of both lungs. In the ordinary cases the mucous mem- 
brane of the middle and large-sized bronchi and even of the 
trachea is affected. This membrane becomes swollen and con- 
gested, the capillaries are engorged, the mucous glands cease to 
secrete. Then the columnar epithelium begins to desquamate, 
and when once destroyed it is not renewed during the process of 
the disease. On the other hand, the basement membrane is not 
to any noteworthy extent disturbed. Within a short time the 
congestion subsides somewhat and the muciparous glands begin 
to secrete vigorously. The secretion becomes mixed with exfoli- 
ated epithelium and small round cells, with many white cells and 
a smaller number of red cells. The deeper epithelial layers 
increase and remain attached to the basement membrane. 

One should keep in mind that the inflammatory process is not 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 257 

in all cases sharply defined. On the contrary it may spread in 
any direction. Frequently enough it extends to the pleura so 
that all grades of this disease may result. Or instead of spread- 
ing widely, it may show an unusual virulence in small dissemi- 
nated areas. In such cases one sees a bronchitis with associated 
small areas of pneumonitis, the whole condition being to all intents 
and purposes a form of broncho-pneumonia. This is especially 
apt to occur in infants. Likewise they show much greater en- 
largement of the bronchial and lymphatic glands than do older 
patients, and are more deeply affected by absorption of small 
amounts of the pus which may be formed here and there in the 
affected area. 

In the cases that recover, no permanent changes in organic 
structure remain, although a variable time may elapse before the 
previous normal condition is thoroughly reproduced. But after 
death from the disease one sees on section a congestion of the 
vessels and mucous membrane, some pus-cells and broken-down 
epithelium, new epithelial growth, and a muco-purulent discharge 
in the bronchi. 

On account of the disability of certain parts of the lungs and 
the strong respiratory efforts of coughing, more or less emphysema 
is apt to supervene. Indeed, I believe that this complication, to 
which young children are prone, happens more frequently than is 
usually accredited. Or the disabled parts are liable to fall into 
a state of atelectasis or partial collapse, the latter occurring gen- 
erally in small areas. Other complications, such as broncho- 
pneumonia and the various forms of pleurisy, are fairly frequent. 

Symptoms. — The symptoms of bronchitis, while on the whole 
following a general course, change considerably according to the 
age of the patient and the intensity of the pathological invasion. 
In the majority of cases one often finds the attack beginning 
with coryza and slight conjunctivitis, a variable appetite, moder- 
ate or slight fever, and general malaise. The cough is at first 
hard and dry, the chest is evidently sore, and the child is plainly 
seen to suffer additional pain with each attack of cough. The 
sleep is disturbed and uneasy, and on waking he seems not to be 
rested. After two or three days the cough is looser and clearly 
less painful, and the patient breathes much more easily. Since 
young children swallow the sputum, at no time need we look for 
expectoration. 



258 



THE MEDICAL DISEASES OF CHILDHOOD 



Inspection shows the breathing to be labored and hurried. 
Fremitus may be somewhat increased. One hears scattered rales 
all over the chest, but in the later stages these signs are most 
plainly heard in the posterior part and lower half. In infants one 
does not look for the classical sibilant and sonorous character as 
regularly as in adults or even in the older children ; indeed one 



PUL. 


RESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


g 


9 


10 


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15 


170 


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PULSE, RESPIRATION AND TEMPERATURE CHART OF ACUTE BRONCHITIS.. 
AGE, 7 MONTHS. 
J>U.L8E.._ t ____ - , .RESPIRATION __.__.__ tfmpfratiirf 

Fig. 37. 



is apt commonly to find a wide variety of sounds, mostly mucous 
These are smaller in the congestive stage, becoming larger, looser, 
and less compact as resolution sets in. 

Respiration is hurried and outstrips the pulse-rate. Espe- 
cially in very young infants it may attain a startling rapidity, 
while at the same time the general condition may be fairly good. 
The ordinary cases, as a rule, do not suffer much from interfer- 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 259 

ence with the circulation. The temperature varies between 
normal and 38.5° C. (101.5° F.). When these averages are 
largely exceeded there is generally more or less severe systemic 
poisoning or a complication with a concurrent disease. There 
is apt to be some cyanosis, especially in severe attacks, which is 
in proportion to the dyspnoea. 

Occasionally one sees cases that begin with great general 
disturbance, very rapid respiration- and pulse-rates, and high 
temperature. These attacks happen for the most part at night, 
and by the next day the child is in an almost normal condition. 
This state of things I have seen almost exclusively in infants. 
It is in all likelihood due to spasm of the muscular coat of the 
bronchioles, with or without the presence of toxaemia. All in 
all, one should regularly expect to see the severest effects of the 
disease in infants, rather than older children who are much more 
liable to dyspnoea, cyanosis, and suffocative invasions than adult 
patients. Their anatomical peculiarities make a rapid extension 
of the inflammation to the capillary bronchioles comparatively 
easy ; and with this go higher temperature, pulse, and respiration ; 
the prostration is more pronounced, the anorexia or inability to 
nurse is plainly noticeable, and resolution is more delayed. The 
more fragile and delicate the child, the greater is the exaggera- 
tion of these symptoms. 

Very often one sees disorders of the alimentary track brought 
on, in part, by the swallowed sputum with its irritating chemical 
characteristics, its difficultly digestible elements, and its bacteria. 
As a result one sees frequent attacks of vomiting, especially 
after coughing. The existence of a bronchitis in the presence 
of a tendency to gastritis, or vice versa, is highly favorable to 
the development of both diseases. 

The nervous symptoms in some infants are marked, but rarely 
do they indicate a graver outcome of the disease. 

Treatment. — In the treatment of acute bronchitis nothing is 
of more importance than the general care and nursing. Children 
should be kept in bed and well protected, although not too warmly 
covered. The intestinal track should be emptied, preferably by 
fractional doses of calomel, followed by an ordinary cathartic ; 
and the food should be as digestible as possible. Fever calls for 
thorough sponge baths or cool packs, and in addition the use of 
warm baths morning and night is to be praised. The extremities 



260 THE MEDICAL DISEASES OF CHILDHOOD 

should be kept comfortably warm, and on the body there should 
be no undue burden of clothes. The mouth, throat, and nose 
should be thoroughly sprayed and cleansed with an alkaline or 
boric acid solution. The child should not be allowed, in order 
to prevent hypostatic congestion, to remain too long in one 
position. 

Counter-irritation, produced by rubbing the chest, front 
and back, with camphorated oil, should not be neglected. Oil- 
silk jackets, plasters, and. poultices I believe, after systematic 
trials, are unnecesssry or even harmful. We can easily do with- 
out the increased liability to colds and congestion, as well as the 
clogging up of the skin, which they are apt to produce. On the 
contrary, the use of serviceable wool underwear is safer, more 
rational, and more desirable. 

Medicines do not necessarily, most of all in the light cases, 
play the most important part in the treatment. Inhalations of 
steam or lime-water vapor are often a means of quieting the 
cough. The use of the strong disinfectants in vapor is of doubt- 
ful additional benefit. With the older children creosote may, 
after the onset of the disease, prove valuable. But if the milder 
inhalations are at all used, they should be liberally administered. 
In the first part of the attack, where the cough is hard, wearing^ 
and continuous, one can give much relief by small doses of am- 
monium chloride with fairly generous amounts of bromide of soda. 
When the disease has a clearly marked spasmodic character, the 
liberal use of antipyrin with a cardiac stimulant will give prompt 
and satisfactory results. Not often is it necessary to resort to 
opium in any form for very young patients, but older children do 
obtain relief from small doses of the deodorized tincture. In very 
nervous cases, where neurotic symptoms are plainly emphasized, 
small doses of codein will give much relief. Throughout the 
whole sickness there may be attacks of prostration or collapse 
that require the administration of stimulants such as whiskey or 
nux vomica. Later on in the attack, especially from the be- 
ginning of resolution and convalescence, small doses of terebene 
or creosote in some of the malt preparations may be used. The 
function of expectorants is commonly overrated, especially in 
young children. Their place is in the treatment of older chil- 
dren whose expectoration is thick and copious. 

It is important to remember that this disease is apt to attack 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 261 

children who are in a debilitated condition. Also, children who 
are fairly strong at the beginning are apt before the sickness has 
disappeared to be much weakened. Therefore, a proper attention 
to tonic remedies is imperative ; and especially during and after 
convalescence such methods as will do most to build up the droop- 
ing vitality are sure to give satisfaction. For this purpose small 
doses of strychnine or nux vomica in combination with the organic 
preparations of iron may be safely recommended. Other tonic 
preparations that may be profitably used, so long as the child's 
stomach is in fairly good working order, are cod liver oil in a 
good emulsion, and the compound syrup of hypophosphites. 

Prognosis. — As there is so wide a difference between the very 
mild and the very severe forms of bronchitis, the prognosis varies 
accordingly. The younger the child, the severer is the disease 
apt to be. In infants it is a really serious disorder ; but as the 
children approach the age of puberty its likelihood of producing 
serious results decreases progressively. With proper attention 
the outlook is not as a rule grave. 

Differential Diagnosis. — In most cases there is very little 
doubt concerning the nature of the disorder ; but occasionally, 
and especially in the severe cases, it may be possible to confuse 
this disease Avith a pneumonia. In infants there is always the 
danger of an extension of the inflammation to the very fine tubes, 
and the resulting formation of a broncho-pneumonia. In either 
of these events the presence of consolidation and its character- 
istic objective symptoms will point the way to the right opinion. 
Also, it is possible that pleurisy with effusion might cause some 
doubt. This is most apt to happen if the amount of fluid is small 
and the chest walls thick. But careful inspection, percussion, 
and auscultation should clear up any obscurity, at all events after 
the child has been seen more than once. It is likewise possible 
that enlarged mediastinal glands may by pressure cause a cough 
that simulates some of the appearances of bronchitis. But here 
the acuteness of the attack is absent, and there is in addition the 
diathetic disorder which precedes such enlargement. When the 
physician makes his first examination of a moderate case of bron- 
chitis, he must always keep in mind the possibility that the disease 
is preceding or accompanying one of the acute fevers, such as 
measles, epidemic influenza, or even whooping-cough. 



262 THE MEDICAL DISEASES OF CHILDHOOD 

Chronic Bronchitis 

The causes of this disease are such as would logically produce 
it. First of all, as a predisposing cause, one should consider a 
general debility, either congenital or produced by adventitious 
causes. The rachitic, the syphilitic, the tubercular, the poorly 
nourished child, the sufferer from the impeded circulation of 
cardiac disease, are much more apt to suffer from a tedious and 
destructive bronchitis of long standing than a healthy and well 
cared for patient. Or a child who has been straining and choking 
with a protracted whooping-cough may make favorable condi- 
tions for the development of this disorder. Deformities of the 
chest which give rise to abnormal positions of the viscera, with 
the accompanying tendency to faulty development and congestion, 
may act as a fertile cause. When a weak and badly nourished child 
has suffered from an acute bronchitis or broncho-pneumonia, or from 
any cause producing a long standing congestion and an obstinate 
cough, the chances of his being afflicted with a chronic bronchitis 
are very good. Extensions or repeated attacks of the acute form 
are naturally the most fertile causes. 

Lesions. — The lesions differ but little from those in acute 
bronchitis. The bronchi and bronchioles become thickened and 
hard, the mucous membrane instead of regaining its normal con- 
dition is heavy and inelastic, lacking in tone. In such an unplia- 
ble state the liability to form cylindrical and sacculated dilatations 
or areas of bronchiectasis is, as one can imagine, comparatively 
great. The air-spaces and bronchioles are filled with a thick and 
viscid exudate, which contains a greater amount of fibrinous 
material than does the thin secretion of the acute form. 

Symptoms. — The symptoms consist of the cough, of the phys- 
ical deterioration, and the subsequent physical alterations which 
result from these factors. The cough is not apt to be so hard as 
in acute bronchitis. There is a variable amount of sputum, but 
more is expectorated in the morning on arising than at any other 
time. The child complains of general disability, of loss of flesh 
and strength. The chest may, on inspection, seem unnaturally 
or irregularly puffed out. Commonly there is no rise of temper- 
ature, although the respiration and pulse may be slightly faster 
than is normal. The other physical signs are much the same as 
in the acute form. One should keep in mind that associated with 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 263 

this disease one finds here and there emphysematous spots or a 
bronchiectasis ; the peculiar hyper-resonance of the one and the 
muco-purulent or purulent discharge of the other will then natu- 
rally show itself. 

The course of the disease is slow, with periods of remission and 
exacerbation. These changes follow quite closely the fluctuations 
in the child's general condition. This is often so poor and deli- 
cate that the patient succumbs to comparatively slight attacking 
causes. The right heart and the large veins are dilated Bron- 
chiectasis and emphysema in varying amounts are apt to result 
from a chronic bronchitis. 

Treatment. — The treatment is mainly a matter of general 
care, climate, and tonics. The child should be clothed in wool, 
should have his diet carefully arranged, should take as much of 
the easily digested fats as possible, should be carefully controlled 
in the matters of bathing, sleep, and exercise. It is of the greatest 
value to take him to a warm and clear climate where the changes 
are not extreme. Such treatment will commonly do more than 
drugs can ever hope to accomplish. In the way of tonics, it is 
wise to adhere to the compound syrup of hypophosphites, to cod 
liver oil, or at times to such other particular remedies as each 
case may call for. Considerable temporary relief for the cough 
may be had from inhalations of the steam of water, lime-water, 
and, in older children, creosote. Codein may give relief to the 
nervous cough or general nervous symptoms that are commonly 
seen in this disease. 

Any primary disease or antecedent condition which persists 
will call for its appropriate treatment before one may look for 
much betterment of the chronic bronchitis. 



Acute Bronchopneumonia 

Broncho-pneumonia, formerly called catarrhal, lobular, or cap- 
illary bronchitis, is a disorder combining many of the features of 
bronchitis and lobar pneumonia. Its frequency of occurrence in 
children is in inverse ratio with their age ; and the serious danger 
of it follows a similar rule. In certain aspects it is hard to decide 
whether this disorder should be classified as a distinct and sepa- 
rate disease, as a combination of two or more diseases, or an 
extension of a primary disease. There is much to be said in 



264 THE MEDICAL DISEASES OF CHILDHOOD 

favor of the view that it may be a " mixed infection," a massing 
of symptoms that vary, as one or another of the elementary lesions 
predominates. Any other view makes it hard to understand its 
manifold appearances, its remarkable changes, its lack of unity in 
typical form. One can make out an indefinite number of individ- 
ual forms in which it may appear ; and only by the exercise of a 
fair amount of scientific imagination may these be* grouped in 
large classes. At all events we know that broncho-pneumonia 
attacks very young children, that weak, debilitated, and rachitic 
children are most easily affected and killed by it, and that it has 




Fig. 38. — Normal Lung. X 25. 

no absolutely typical course, duration, or method of ending. The 
whole appearance of the disease impresses one as that of a sick- 
ness which is much influenced by the physical condition and 
environment of the patient. Herein it differs from lobar pneu- 
monia, which seems to attack with equal virulence both the strong 
and the weak. 

Where the child has been suffering from a bronchitis or any 
of the acute infectious fevers, broncho-pneumonia may frequently 
supervene as a complication. The specific toxines of these fevers 
seem to have an important influence in predisposing toward the 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 265 

disease, most of all when they are very severe or where the pa- 
tient is unusually weak. In most cases the direct and acting 
cause of the sickness is some forms of pathogenic micro-organ- 
ism such as streptococci, pneumococci, or staphylococci, in pure or 
mixed cultures. Subsidiary factors are the inhalation of irritat- 
ing substances, hypostatic congestion, and unhygienic surround- 
ings ; and harsh weather and sudden changes of atmospheric 
conditions may probably have some influence as auxiliary cir- 
cumstances. 




*.» 



>..#» 



<tf 




&L * 



\fe 



Fig. 39. —Broncho-Pneumonia. X 100. 



Lesions. — The main lesion is an inflammation of the walls of 
the bronchioles and air-cells. The inflammation of the mucous 
membrane does not play so important a role as in lobar pneu- 
monia. The walls of the bronchioles and air-spaces are thick- 
ened and infiltrated. The spaces themselves are filled with the 
products of inflammation, with epithelial cells and shreds of epi- 
thelium, blood-cells, pus, and fibrin. In some cases the capillaries 
become so congested as to encroach upon and fill up the area of 
the air-spaces. In other cases the affected parts become thor- 
oughly infiltrated with sclerotic tissue, with the natural result 
that their characteristic activity is lost. This process may take 



266 THE MEDICAL DISEASES OF CHILDHOOD 

place in the walls of both air-spaces and bronchi, so that complete 
recovery is hard to obtain. This interstitial material may be so 
extensive that considerable parts of lung are thus rendered use- 
less and become the starting-ground of a chronic process of tuber- 
culosis. An additional aid to this result is atelectasis, which 
occurs in patches and mostly in the thinnest and most remote 
portions of lung tissue. This is brought about by the occlusion 
of the small bronchi, mostly by mucus or by a lack of the normal 
respiratory force. As a natural sequence, other parts, having to 
do more than their share of work, become, on account of the strain 
of coughing and over-exertion in breathing, emphysematous. 
These emphysematous spots are for the most part found in or 
near the apices, in compensation for the clogging of the lower 
portions of the lung which in this disease are more often affected. 
For analogous reasons the tubes dilate irregularly and mostly in a 
cylindrical shape. 

As a general rule the larger bronchioles are not involved and 
the inflammation is irregularly disseminated. However, all cases 
do not adhere to this strict form, but have in addition inflamma- 
tory changes in allied and adjacent structures, such as the mucous 
membrane, pleura, and the surrounding lung tissue. This exten- 
sion may proceed even as far as the trachea, although it progres- 
sively becomes fainter the farther it spreads from the centre of the 
disease. Where it is most intense there may be small collections 
of pus, of broken-down epithelium and cells, each of which areas 
has its small surrounding space of pneumonitis. 

Excepting in cases where the characteristic changes are not 
marked, there are peribronchitic areas of true pneumonitis which 
spread with the extension of the original disease. Such cases may 
start with small and widely separated localities of inflammation, 
but the lapse of a few hours or days changes materially the con- 
dition of affairs. Occasionally these areas approximate so closely 
that they eventually give the appearance of a large original tract 
of pneumonia. There are some special types which should be 
mentioned : — 

(1) In some very young infants these extensive changes do not 
occur ; the affected portions are for the most part collapsed and 
oedematous, having neighboring areas of emphysema. 

(2) Occasionally one meets with a broncho-pneumonia which 
is exceedingly rapid in progress. The occlusion of bronchioles 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 267 

and air-spaces is accomplished in a few hours, and the breaking 
down of both normal and abnormal tissue is marked. 

(3) There is another irregular form, characterized by strong 
interference with the circulation, which is caused by an exceed- 
ingly rapid diffusion of the products of inflammation. Conse- 
quently the breathing is labored and the cyanosis is extreme. 

On account of the interference with the circulation and the 
compressed state of the lung tissue, the right heart is enlarged 
without a commensurate thickening of its walls. Also the large 
veins are dilated. 

In gross section the characteristic appearance consists of the 
involvement of scattered lobules. These project above the plane 
of the cut surface and are harder than the surrounding surface. 
There is a distinct contrast between them and the shrunken 
areas of atelectasis, especially as the latter are dark and cyanotic 
in color. The lower and posterior parts of the lungs show the 
greatest amount of congestion. The emphysematous spots are 
softer and more crepitant to the touch, especially as the most 
characteristic parts are most airless. Here and there in the 
peribronchitic zones of pneumonitis may be seen minute collec- 
tions of pus. There is, besides, an exudate of clear or semi- 
purulent mucus. 

The pleura may have a coating of fibrin, or may be the seat 
of a marked inflammation. In the more protracted cases it may 
even be bound down by fairly strong adhesions. A purulent 
pleurisy is a common sequel, and is liable to run a very severe 
course on account of the exhaustion produced by the original 
disease. The larger bronchi and trachea may be congested and 
covered with fibrin. The involvement of these structures, and 
their lack of tone that is brought on by the strain and stress of 
coughing, may start a bronchiectasis of varying size and form. 

Symptoms. — The most audible physical signs may be noticed 
at the back and sides, particularly in the lower parts, and usually 
in both lungs. Inspection shows the breathing to be labored, 
and instead of the abdominal it assumes the thoracic form. The 
pause in respiration comes before instead of after expiration. 
As one would expect, the expansion of the lungs is imperfect and 
irregular, the lower part of the chest and the intercostal spaces 
recede on inspiration, and the nostrils work convulsively with 
each respiratory effort. Dyspnoea is usually present, accom- 



■■ 



268 



THE MEDICAL DISEASES OF CHILDHOOD 



panied at times by varying degrees of cyanosis. It is impossible 
in some very young infants to get anything more definite than 
this ; but in older patients vocal fremitus may be increased over 
the affected area excepting those parts where atalectasis exists. 

The percussion note varies with the affected areas, so that 
the predominance of the pneumonic or bronchitic element in turn 




PULSE, RESPIRATION AND TEMPERATURE CHART OF BRONCHO-PNEUMONIA, 
AGE, 13 MONTHS. • 

PULSE _ _______ RESPIRATION __.,____, TEMPERATURE _______ 



Fig. 40. 



becomes apparent. Often one may notice a distinct dulness, 
especially where the affected area is sufficiently large. Again, 
this sign may be absolutely lacking, possibly on account of a 
central location of the inflammation or some peculiar position. 
Moist rales, both fine and coarse, may be heard scattered over 
the chest, while small dry crepitant rales sometimes occur at rarer 
intervals. In the older infants and children one may expect to 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 269 

hear a fairly distinct bronchial breathing, which in the younger 
may change and fade away to a sound that is merely harsh. 
Resonance is likewise variable ; and where there is emphysema 
one may also find hyper-resonahce. 

The symptoms are not quite so characteristic as those of lobar 
pneumonia. Where the broncho-pneumonia complicates an infec- 
tious fever there may be at first no more than an exaggeration of 
the evidences of fever, dyspnoea, and malaise. Or the attack may 
be ushered in with a chill, with vomiting, or diarrhoea, cough, and 
pain. The fever rises irregularly and intermittently, usually 
having a maximum of 40° C. to 41.1° C. (104° to 106° F.), 
generally at night. In rare cases of profound toxic absorption 
the temperature may even be somewhat higher. The respiration 
and pulse are likewise irregular, but follow the general course of 
the thermometer, the former ranging from 50 to 80, the latter 
from 100 to 200. These figures are, of course, approximate. 
There is a class of unfavorable cases in which the fever line 
remains low or even drops to subnormal. Here there is, as a 
rule, marked weakness, the pulse and respiration vary consider- 
able from time to time, and the whole picture is one of flagging 
vitality. 

The cough at first is short and hacking, and, especially in 
children of a nervous disposition, may become continuous and 
very severe. In infants, and sometimes in older children, there 
is no expectoration because the sputum is swallowed. Where 
the child is being exhausted, the breathing becomes progressively 
more hurried and shallow, cyanosis is apt to be marked, and the 
little patient may become stupid or fall into convulsions. Occa- 
sionally in serious cases one meets with Cheyne-Stokes respiration. 
Such children are likewise apt, in case they recover, to have a 
delayed and tedious convalescence. On the other hand, if the 
disease assumes a milder type, the patient begins from the sixth 
to the ninth day to show a definite improvement. The breathing 
becomes easier, the color more natural, the cough looser, and the 
appetite somewhat more vigorous. 

There are a few cases where one sees no symptoms except a 
small increase in the temperature and respiration, slightly harsh 
breathing, and some general malaise. The cough may be insig- 
nificant or absent. One becomes aware of such an attack after 
it has served as the basis of a chronic broncho-pneumonia or a 



■i 



270 THE MEDICAL DISEASES OF CHILDHOOD 

tubercular process, of a dilated heart or a pleuritis. When death 
occurs, it is in infants mostly due to toxyemia or interference with 
respiration ; in older children to heart failure. 

The heart, stomach, spleen, and kidneys — in fact all the 
abdominal and thoracic viscera — may become the seat of an 
acute exudative inflammation which may be recognized by the 
characteristic symptoms, 

The outlook is always a serious one, especially as the disease 
is apt to be a long and wearing ordeal. When it complicates the 
acute infectious fevers the prognosis is truly discouraging. In 
the cases that recover, convalescence as a rule comes gradually ; 
in some rare cases the disease is limited by a distinct crisis. 

Treatment. — Complications involving the heart, pleura, or 
meninges may result, and need scrupulously faithful attention. 
The treatment of broncho-pneumonia demands judgment, sym- 
pathy, and care. An exact and rigid over-sight of the details 
of nursing is of the highest importance. This is all the more 
to be observed because there is no specific treatment with 
drugs. At the beginning the bowels should be emptied by 
repeated small doses of calomel followed by a saline cathartic. 
Where the disease occurs as a complication or a secondary dis- 
order, the treatment is in the main that of the primary sickness. 
It may be necessary to use a drug to sooth an irritable cough ; 
and for this purpose one is safe in using the bromide of soda, 
which very young infants tolerate even in comparatively large 
doses. In older children one may use this same remedy, or, where 
it is insufficient, very small doses of opium. The temperature 
should be controlled, not by the synthetic antipyretics, but rather 
by cool sponging, cool and tepid packs, and the graduated bath. 
In cases of marked weakness, cold extremities, or cyanosis, one 
should employ warm packs and baths and eschew the use of cold. 

It is of the very highest importance to keep up the patient's 
strength. One must be prepared for a long siege of sickness, and 
therefore must be ready to face the problem of constantly recur- 
ring attacks of weakness or a persistent condition of asthenia. 
The gradual unfolding of all of one's resources in the way of 
stimulants and tonics permits one to use much fine judgment 
and clear thought. On the whole, and excepting cases of sudden 
collapse, one can do without much whiskey and brandy. And 
when there are gastro-intestinal disturbances it may be advisable 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 271 

to give them by rectum rather than by mouth. One can, in many 
cases, get along better with strychnine or nux vomica, which 
should be reenforced by sufficient doses of digitalis. Occasion- 
ally, where the bronchitis is the predominant feature, there may be 
a need of steam inhalation ; or the patient may require small 
doses of potassium iodide to liquify the thick mucus which he 
strains to expectorate. The use of oxygen in inhalations has 
been praised in the past ; but at the present time the tendency of 
the opinion is much less favorable. Many observers believe that 
it gives no help at all. 

Since broncho-pneumonia is so often the concomitant or the 
sequel of debility, one naturally expects a hypostatic congestion 
occurring in the course of the sickness. Conscientious care will 
minimize this lesion, which otherwise may act as the determining 
factor against the immediate or eventual recovery. It is wise to 
vary the position of the patient from time to time, at the same 
time consulting his ease. 

Food should be given in small amounts and frequently. It is 
hardly necessary to say that it should be fluid and as easily diges- 
tible as possible. More harm than good can be accomplished by 
overloading the stomach. 

The ideal treatment for this disease would be by means of an 
antitoxic serum. The experiments have up to this time been 
unsuccessful, partly on account of inability to ascertain before 
death what germ is at the basis of the sickness, and partly be- 
cause the disease almost always represents a mixed infection. 

Prognosis. — Broncho-pneumonia is always a dangerous dis- 
ease, especially in infants, and when it complicates the acute 
infectious fevers. One of its worse features is the likelihood of 
delayed resolution, with the attendant physical debility and the 
opportunities for the growth of chronic processes. In ordinary 
private practice the mortality ranges from fifteen per cent to 
thirty per cent ; but in hospitals and institutions for children it 
is twice as large. In giving an opinion about the probable out- 
come, one should be guided by the patient's age, his vitality, the 
presence of other diseases, and the virulence of the broncho-pneu- 
monia as shown by the symptoms. The complicating symptoms 
of disorders in other organs must naturally have a place as factors 
in the equation. 

Differential Diagnosis. — The main features of this disease are 



272 THE MEDICAL DISEASES OF CHILDHOOD 

the gradual onset, the rapid and irregular respiration and pulse, 
the prostration, high temperature, — which frequently assumes a 
remittent type, — the physical signs of scattered areas of con- 
solidation, and some degree of dyspnoea. One must be prepared 
for the development of a broncho-pneumonia from a severe 
bronchitis or a bronchitis that has been neglected. And in the 
acute eruptive fevers an exacerbation of the symptoms is com- 
monly due to this cause. When the items mentioned above exist, 
the disease should be suspected even if the physical signs in the 
lungs are not clear. It is possible, but not probable, that some 
doubt may exist between a diagnosis of broncho-pneumonia and 
that of pleurisy with effusion. But if one keeps in mind the ob- 
jective symptoms which the presence of fluid creates, the difficulty 
should promptly fade away. 

The disease which is most readily confounded with broncho- 
pneumonia is lobar pneumonia. The diagnostic points between 
them are given in the account of the latter disorder. 

Chronic Broncho-Pneumonia 

Causes. — In weak and debilitated children recovery from an 
acute broncho-pneumonia may be indefinitely delayed; or suc- 
cessive attacks of the acute form may follow each other closely 
enough to make each attack harder to throw off than the preced- 
ing one. In either of these cases a chronic broncho-pneumonia 
may result. 

Lesions. — Outside of the regular inflammation with which we 
are acquainted in the acute form, the fact which will impress us 
as most noteworthy in the microscopical examination of this dis- 
ease is the large amount of connective tissue that is laid down 
around the bronchioles. In cases that are not too far advanced 
this shows on section as small, light fibrous nodules. Where the 
disease is farther advanced, these peribronchitic areas spread out 
and merge, so that finally one sees a section of a lobe or even an 
entire lobe reduced to solid connective tissue. The exaggeration 
of this process has sometimes been called by the faulty name of 
fibroid phthisis. In the chronic form of broncho-pneumonia not 
only does a portion of a lobe succumb to connective tissue changes, 
but also the alveolar and bronchial walls are likewise thickened, 
the pleura is bound down to the lung by adhesions, the alveolar 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 273 

spaces may become filled with exudate, and thus obliterated. Fol- 
lowing these changes, the smaller and medium-sized bronchi may 
be distorted, dilated, and sacculated. But these parts are not the 
only ones that suffer ; even the pulmonary pleura may likewise be 
involved, and become thicker and less elastic than in health, as 
well as bound down by adhesions. Such a condition favors the 
development of tuberculosis ; and many of these cases finally be- 
come tubercular. 

Symptoms. — The symptoms are very disturbing. Even with- 
out the strain due to the cough, the child becomes very much 
exhausted and emaciated. He suffers from periods of fever, at 
which times the pulse and respiration are somewhat heightened. 
He now and then is markedly prostrated and cannot avoid being 
attacked by intercurrent illnesses. His appetite and sleep are 
poor, the loss of flesh and strength is progressive. Rarely the 
formation of a bronchiectasis shows itself in the profuse muco- 
purulent or purulent expectoration, which is commonly most pro- 
fuse in the morning. The whole picture is that of a wasting 
disease, and with it may be associated a simple or tubercular 
inflammation of the bronchial and lymphatic glands. Also one 
may find areas of emphysema. The course of the disease is a 
wearisome succession of exacerbations and remissions in the pul- 
monary complaint, the causes of which are at times hard to locate. 

Inspection may show the chest to be retracted on the injured 
side. Where the sclerotic tissue exists in large amounts one finds 
dulness on percussion, poor respiratory murmur, and increased 
vocal fremitus. One is immediately impressed by the idea that 
the characteristic structure of the lung has been changed and 
abolished. 

The child is very apt to become tubercular in other parts of 
the body than the lungs. 

Treatment. — The treatment consists for the most part in at- 
tention to the general care and the climate. The food, clothing, 
rest, bathing, and exercise must be most scrupulously regulated, 
and every attempt should be made to keep the patient's vitality 
as high as possible. He should be removed to a warm and dry 
climate where he will not be oppressed by great and harmful 
barometric and thermometric changes. The best tonics at our 
command should be given. The selection of these must be made 
to suit individual cases. 



274 THE MEDICAL DISEASES OF CHILDHOOD 

Prognosis. — Some^ but not many, of these cases recover. In 
general the outlook depends upon the patient's vitality, his en- 
vironment, and the ability of his parents to provide all the various 
helps that intelligence and money can give. Even where death 
does not result, a complete return to health and strength is 
scarcely to be expected. 

Differential Diagnosis. — The diagnosis lies between chronic 
broncho-pneumonia and a tubercular process. The question is 
decided against the latter by inability to rind the characteristic 
signs of tuberculosis or the specific bacillus. 

Interstitial Pneumonia 

This is a disease that is not often seen in children. And 
when it does so occur it is always a noteworthy process, because 
the development of infantile tissues lies away from the great in- 
crease in the connective tissue elements. All their efforts in 
growth are directed to an increase and development of paren- 
chyma ; but a growth of sclerotic tissue is essentially senile in 
its nature. 

Causes. — Given a weakened nutrition, or exhaustion brought 
on by diathetic disease, with repeated attacks of pleurisy, pneu- 
monia, or bronchitis, and the possibility of an interstitial inflam- 
mation is always present. Not only do adhesions between the 
lung and pleura bind and distort the tissues, but also an analogous 
production of connective tissue may gradually follow. In a few 
other cases a scar of a healing cavity may act as the starting-point 
of an interstitial process. 

Lesions. — The disease may start in any part of the lung, may 
extend in any direction, may involve any amount of tissue. The 
appearance on post mortem examination is very striking : adhesions 
bind the thickened pleura to the lung and the chest wall, squeez- 
ing and twisting the lung out of its normal shape and position. 
The tough adhesions may pierce the surface of the lung and make 
their way through the pulmonary substance. All over the af- 
fected area the laying down of connective tissue spreads slowly 
and gradually until every element is involved. The bronchioles, 
as the surrounding tissue contracts and recedes, become irregu- 
larly dilated and enlarged. The lung loses its characteristic 
structure and remains homogeneous and undifferentiated. 



DISEASES OF THE BRONCHI, LUXGS, AXD PLEURA 275 

Curiously enough, one lung only is involved. Then, the other 
lung being forced to do more than its share of the work, becomes 
emphysematous. Where only a part of a lung is attacked, the 
neighboring areas must in the same way become emphysematous 
until they in turn become absorbed. 

In some few cases of marked adhesions the pericardium is 
involved along with the pleura and lung surface. In these 
especially does the general rule of glandular enlargement hold 
good. The. whole condition is one which invites invasion by the 
tubercle bacillus. 




Fig. 41. — Chronic Interstitial Pneumonia. X 30. 

Symptoms. — The symptoms of this disease are often difficult 
to recognize in a clear fashion. One is constantly liable to be 
misled by a history of an ordinary sub-acute or chronic cough 
which started in some of the common pulmonary disorders. 
There is finally a more or less lengthy period of delicate health, 
lack of resistance to the attack of coughs and colds, flabby physical 
development. There may be no elevations of temperature, and 
interference with the regular rates of respiration and pulse will de- 
pend upon the extent of the disease and the amount of distortion. 
In each case the observer will have to work out such factors himself. 



276 THE MEDICAL DISEASES OF CHILDHOOD 

Over areas of interstitial tissue percussion gives a dull note, 
over emphysematous parts hyper-resonance, and over a bronchiec- 
tasis a cavernous note. There is very apt to be more or less 
bronchitis or a low grade of broncho-pneumonia which must 
give their characteristic symptoms. In advanced cases deformi- 
ties of the chest wall and position of the heart may be striking. 
As the lung tissue becomes obliterated, the respiratory murmur 
becomes fainter and fainter until it finally may cease. At. any 
time these symptoms may be increased by those of acute or sub- 
acute tuberculosis. 

Treatment. — The only treatment consists in conserving and 
developing the patient's vitality by the strictest attention to diet, 
hygiene, tonics, and climatic changes. There is no drug that by 
itself is able to stop the disease ; and often one can do little more 
than treat the symptoms. If the patient's environment is good, 
his chances for life may be bounded by a few years. If he is 
attacked by an intercurrent disease, the difficulties of successfully 
caring for him are very much increased. 

Prognosis. — While life may be prolonged for months or years, 
there is little hope for permanent cure and a return to health and 
strength ; moreover it is impossible to say how long these cases 
will live, for the most surprising changes are apt to occur. 

Differential Diagnosis. — The diagnosis lies between the in- 
terstitial pneumonitis and pulmonary tuberculosis. Usually it 
is not difficult to exclude the latter, since the symptoms of fever, 
night sweats, the involvement of other parts of the body, the find- 
ing of the specific bacilli in the sputum, and the general impres- 
sion of tuberculosis are absent. 



Secondary Pneumonia 

As the result of pronounced weakness, prostration, and 
engorgement of the pulmonary small vessels, a child may be 
affected with a low form of inflammation that may be called a 
secondary pneumonia. 

Causes. — The recumbent position, most of all when the 
patient's posture is not from time to time changed, is in fact 
responsible for the condition. The severe wasting diseases are 
those most apt to debase the child's physical state to such a 
degree that the tone of the tissues is seriously impaired. If the 



DISEASES OF THE BRONCHI, LUNGS, AXD PLEURA 277 

antecedent disease is markedly microbic in nature, the germs are 
apt to find a fertile culture-ground in the weak and atonic pul- 
monary structure. 

Lesions. — The posterior parts of the lungs are the ones most 
affected. A broad strip on each side may be involved from top 
to bottom, or the lesions may be scattered in small areas here and 
there, but without penetrating into the interior. Some of the 
cells may be aerated, others will be in a condition of red and 
gray hepatization. In the latter position the arterioles are con- 
gested, there are a diapedesis of red cells and an emigration of 
white cells. Also one may see mixed with them epithelial cells, 
pus, and fibrin. 

In some few cases the inflammation seems to centre about the 
smallest bronchioles, each of which may have a small zone of 
peribronchitic pneumonitis. These bronchioles would then be 
subject to the usual degenerative changes and be filled with the 
products of inflammation. 

Symptoms. — The symptoms are few and not especially charac- 
teristic. The child's condition is so poor that no definite rates 
of the respiration, temperature, and pulse can safely be given. 
Since the disorder comes only in the wake of some pathological 
condition, these three factors will assume the general character 
which belongs to the precedent disease. There may be a muffled 
sound on percussion and fine rales on auscultation. Here and 
there one may distinguish coarse rales. The breathing is apt to 
weak, shallow, and irregular. 

Treatment. — In the course of any disease which brings with 
it marked prostration, the attendant must keep constantly before 
him the possible supervention of a secondary pneumonia. He 
should require the child's position to be changed from side to 
side, and thus avoid too long an exposure from lying on the back. 
The treatment of the original disease must look to the mainte- 
nance of as much vitality as possible, and should, if at all allow- 
able, include the active administration of efficient tonics. 

Prognosis. — The prognosis, on account of the patient's debil- 
ity, is bad. 

Beoxchiectasis 

By this term is meant a dilatation of parts of the bronchi 
which, in different cases, varies in size, location, and contour. 



278 THE MEDICAL DISEASES OF CHILDHOOD 

These dilatations rarely occur in the largest tubes, and in children 
are more apt than in adults to affect the fine bronchioles. On 
account of their variations in size and shape they have been 
roughly divided into cylindrical and sacculated forms. The first- 
named variety consists of a fairly regular enlargement which 
gradually merges into the normal contour of the tube ; the 
second consists of an abrupt enlargement which need not assume 
any regular form, but may vary all the way from a pouch-like 
dilatation to a practically closed cavity. It is doubtless true that 
the condition occurs more frequently in children than is commonly 
believed. 

Causes. — The constant strain of coughing, the pressure of 
large quantities of mucoid secretion, and the weakened condition 
of the bronchial walls make dilatation a fairly common sequel to 
chronic bronchitis. Occasionally, and more especially in young 
children, it may follow the acute form of bronchitis as well as all 
forms of broncho-pneumonia. It may regularly be expected in 
some degree with emphysema and pertussis ; almost as regularly 
it occurs in interstitial pneumonia and pulmonary tuberculosis ; 
while in a severe pleurisy with extensive adhesions the possible 
extension to the lung tissue of the newly formed bands and the 
distortion to which the lung is subjected are sufficient to weaken 
the bronchial walls and pull them out of shape. In short, any 
severe inflammation which affects the bronchi is capable of pro- 
ducing bronchiectasis. 

Lesions. — In the cylindrical form the bronchial tissue may in 
the light cases be not altered. In the severer ones the mucous 
glands are flattened and wasted. In the dilated portions there 
will be large quantities of mucus with some pus. The lesions in 
the sacculated form are regularly severer than this. The whole 
wall is more or less intensely atrophied and infiltrated with con- 
nective tissue. In the extensive cases one dilatation may succeed 
another until the bronchus retains but little of its normal contour. 
At the same time its structural elasticity may vanish to such an 
extent that to limit the degree of the possible changes is difficult. 
Thus the tissue between dilatations may become so thinned as to 
allow them to communicate ; or the walls of the enlargement may 
become so debased in vitality as to permit the growth of a pyo- 
genic process. 

Symptoms. — The symptoms are often obscure or inappre- 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 279 

ciable. However, the disorder occurs so frequently that weak 
children who suffer much from the pulmonary diseases which 
cause bronchial dilatation should be suspected of having it. In 
some cases there are some mucous rales, the respiratory sound is 
tubular, and over a large bronchiectasis one may discern the per- 
cussion note of a cavity. The expectoration, especially in the 
morning, is apt to be large, so large, in fact, that patients claim 
to vomit it. A peculiarity of it is that on standing it separates 
roughly into three layers. The bronchiectatic patient suffers 
from successive attacks of bronchitis, which often arise without 
sufficient ostensible cause. 

Treatment. — There is no specific medical treatment ; all that 
one can do is so to treat pulmonary cases that the severity of the 
cough may be diminished and the general strength and tissue- 
tone as little impaired as possible. 

The administration of tonics must be consistently carried out 
for a long time, and the general health must be promoted in all 
possible ways. Children w T ho live in cities and in harsh climates 
should be kept in the country where the extremes of temperature 
and the degree of atmospheric moisture are not excessive. In 
addition, one should direct the daily practising of calisthenics 
which tend to promote the activity of the chest and lungs. 
While it is not possible to bring about an immediate cure, con- 
siderable improvement may be made in the child's health and 
strength. The latest and best method of relief is purely surgical. 
It consists of pneumotomy, with drainage. This is really the 
logical cure ; for a bronchiectasis is to all intents and purposes a 
chronic abscess. And the regular treatment for abscess-formation 
must always be incision and removal of pus. 

Acute Pleurisy 

The more one is able to compare the conditions found after 
death in the bodies of children w r ho succumbed to pulmonary 
disease with the symptoms which exist in the progress of sickness, 
the more will one believe in the widespread occurrence of the 
various forms of pleuritis. And when the frequency of this dis- 
order is thoroughly appreciated, when its importance as a primary 
disease and its salient influence as a complication in exhausting a 
patient are put at their rightful value, an important step in the 



MMI 



280 THE MEDICAL DISEASES OF CHILDHOOD 

direction of efficient protection to the sick will be made. In 
adults the evil effects of any and all forms of pleuritis are bad 
enough ; but in children they are both actually and potentially 
very much worse. 

Causes. — The causes which bring about this disorder are 
unquestionably prolific. They are such that neither sex nor social 
condition can make much variation in its occurrence. Moreover, 
there is one important interpretation of this statement : a poor 
physical state, no matter what the cause, renders the child much 
more susceptible than he otherwise would be. Whether this 




Fig. 42. — Normal Pleura. X 85. 

physical degeneration is due to underfeeding or overfeeding, to 
too little or to too much care, the final condition is to all intents 
and purposes the same. Robust health is not an absolute protec- 
tion, but it certainly has some influence in limiting the course 
and severity of the disease. The main fact is that physical dete- 
rioration and deficient vitality lay a child open to attacks of pleu- 
ritis and likewise contribute to the likelihood of those attacks 
assuming the more serious forms. 

In all likelihood this cause of malnutrition plus that of expos- 
ure should be regarded as for the most part contributory. In 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 281 

addition a very slight active agent, such as a blow, a fall, an inter- 
current disease, may start the complaint in full force ; and exten- 
sions of ordinary pulmonary inflammations are almost regularly 
to be expected. Therefore one often sees pleuritis occurring or 
following pneumonitis and bronchitis, the acute infectious fevers, 
especially those of a severe type, severe intestinal diseases, most 
of all in young infants, and even rheumatism. Moreover, when- 
ever the pneumococcus, streptococcus pyogenes, staphylococcus 
pyogenes aureus, or the bacillus of tuberculosis can reach the 
pleura, there is danger of an acute inflammation of it, No age is 
free from it, for even before birth the infection may take place. 
In addition, inflammation, especially of a purulent type, of any 
part of the throat, the lungs, mediastinum, ribs, vertebrae, the 
serous envelope of the heart, as well as abscess or echinococcus 
of the liver, purulent disease of the pancreas, intestines, and peri- 
toneum, and bone diseases have been known to act as irritants. 

The disease, according to statistics, occurs somewhat more 
frequently in boys than in girls, and oftener on the left than the 
right side. However, these are facts of little importance and can 
easily enough be accounted for. 

Lesions. — The different forms of pleuritis are commonly 
regarded or spoken of as different diseases. This can result only 
from an inadequate attention to the pathology and to experi- 
mental researches. As a matter of fact it is highly advisable to 
consider all the various types as phases of one disorder which may 
assume greater or less features of pathological development accord- 
ing to the presence of different factors. In one case we see a 
simple inflammation of the pleura with a rational formation of 
fibrin and fibrous adhesions. In another there is an effusion of 
serum added to the characteristic changes of the first form. In 
still another we find that the effused material has in some way 
become infected with pus-forming elements, and as a result the 
pleural cavity contains larger or smaller amounts of pus. Where 
for proper reasons this pus material is very intense and acrid in 
its nature, we see a gangrenous condition of the tissues. And 
where for special reasons, as in scurvy, there is a tendency toward 
the breaking down of blood-vessels, we have the rare so-called 
hemorrhagic form of pleuritis. But all these processes have a 
common foundation, and vary merely in the superstructure which 
that foundation supports. 



MHHM 



282 THE MEDICAL DISEASES OF CHILDHOOD 

At the first stage of the inflammation, the pleura becomes con- 
gested, its color deepens, the capillaries are plainly injected, and 
the endothelial cells swell up and are shed. Besides these small 
cells white cells also may be seen. Then on the surface of the 
pleura fibrin begins to appear in scattered bits, in threads, in 
spreading areas. One should keep in mind that these changes 
are confined to the surface, and that below the surface the tissue is 
scarcely, if at all, affected. This fibrin, holding in its meshes 
endothelial and pus cells, increases very rapidly in quantity. The 
opposed surfaces become simultaneously affected, and strips and 
strings of fibrin finally join and bind them. The superficial 
layers of connective tissue cells become swollen and enlarged, 
causing with the layers of fibrin a distinct increase in the thick- 
ness of the pleura. This process naturally goes on to the pro- 
duction of new connective tissue cells. When the growth of the 
new materials reaches its height they become organized, and the 
blood-vessels may easily be traced ramifying from the pleura. 

When convalescence sets in the fibrin begins to be absorbed, 
and at the same time the connective tissue increases yet further 
in quantity. As a result the thickening of the pleura goes on, 
but unevenly and in patches. Then the bands of fibrin between 
the pleural surfaces become in the same way organized and 
strengthened, and thus form more or less rigid adhesions. These 
on recovery need not have the same shape and relations as while 
they were forming. On the contrary they may be partly ab- 
sorbed and so produce eccentricities in outline with corresponding 
deformities. 

This is what one sees in a simple pleuritis, called dry or 
fibrinous pleuritis. More frequently one sees a course of the 
disease which in addition to these changes has the characteristic 
of an effusion of serum. This serous fluid contains about five per 
cent of albumin, has a specific gravity of about 1.018, and varies 
in color all the way from a clear amber to the yellow and green 
of pus. It may on the one hand be quite sterile, or on the other 
hand be loaded with great quantities of divers micro-organisms. 
It may contain collections of fibrin and in rare cases, scurvy for 
example, it may hold varying amounts of blood. In quantity it 
maj r range from grammes to litres. When the amount is large, 
the pressure effects may be plainly visible, even so far as to pro- 
duce the most alarming symptoms. At the same time one should 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 283 

remember that, on account of the pliability of the infant chest 
wall, these effects are not so marked as they would be in the 
adult. The effusion naturally forces the viscera in this direction 
and that, according to the line of least resistance. The lung on 
the affected side is pressed upward and back ; or it may be 
hemmed in on both front and back and thus compressed, and at 
the same time the heart is forced away from this side. The dia- 
phragm is pushed down ; the stomach, spleen, and pancreas are 
in similar ways variously affected according to the controlling 




Fig. 43. — Fibrinous (Adhesive) Pleuritis. X 25. 

To the right the visceral and costal layers of the pleura are bound together ; to the left the process is as 

yet incomplete. 

forces. The chest wall is increased in circumference on the 
affected side, the intercostal spaces may be stretched apart and 
bulged out. As the result of these conflicting forces, most of all 
when the adhesions are strong and eccentrically disposed, the 
patient may become afflicted with distortions of the chest walls 
and spinal column. In other cases the fluid by the agency of 
the adhesions may be shut off in curiously shaped cavities. In 
a different class of cases, where there are no adhesions, the 
fluid in an upright chest has a regular location, being lower 



284 THE MEDICAL DISEASES OF CHILDHOOD 

behind than on the sides or front. With changed position there 
naturally follows some change of contour. 

This form of the disease may be designated pleuritis with 
effusion, or pleuritis with fibrin or serum. 

The third form, commonly called empyema, consists in the 
addition to the second form of a purulent element which may 
begin with the inflammation or be secondarily acquired. It 
should be clearly understood that this division is to a certain 
extent conventional, and that the majority of cases have a greater 
or less mixture of characters. Thus the fibrinous form often has 
a small amount of fluid, although not enough to modify the 
symptoms in any considerable degree. Again, the serous type 
commonly has a few pus-cells in the effusion which may, under 
the circumstances of weakness and debility, increase to a great 
extent. Even the purulent form may begin with a compara- 
tively small micro-organic element, which rapidly develops, so 
that in certain cases it comes to be the predominating feature 
of the disease. 

Purulent pleuritis may be of a short or long duration ; in 
infants, even when there is no high temperature, it may continue 
for a considerable period. Nevertheless, one is safe in saying 
that children under favorable conditions of treatment and vitality 
react more rapidly in convalescence than do adults. When pro- 
tracted cases occur the organic changes may be as great as the 
pleural thickening is marked. 

There are a few virulent cases where the purulent exudate is, 
or becomes, gangrenous. Such patients are always very danger- 
ously sick, and the pathological changes rage with intense severity. 
The infected fluid is exceedingly offensive in appearance as well 
as odor, and is characterized by the formation of gases of putre- 
faction. In this last event the pressure effects are decidedly 
greater than where the fluid alone is the active cause. Such a 
condition may be one of the causes of a rupture from the lung 
or the chest wall. The consequent entrance of air would consti- 
tute the condition of pyo-pneumothorax. 

Symptoms. — Palpation shows the lessened movement of the 
chest, and, when there is effusion, much diminished or absent 
vocal fremitus. A case rarely occurs where the fremitus is not 
much altered. As a rule, however, its absence is one of our most 
valuable signs. 



DISEASES OF THE BROXCHI, LUXGS, AXD PLEURA 285 

Percussion gives a dull note over thickened pleura and a flat- 
tened note over the effusion. This note may not be evident at the 
very onset of the disease ; in fact, the child may be sick for 
hours or even days before we get a clearly defined change. The 
variations are not susceptible of intelligible and efficient descrip- 
tion, since we seldom see two cases exactly alike. The comparison 
of a number of cases will demonstrate the differences better than 
words can do. Nevertheless, a few examples will show a peculiar 
heavy flatness which is not easily mistaken. The main source of 
error exists in cases where a thin stratum of fluid allows the sub- 
jacent lung tissue to modify the note. Likewise we must be 
prepared to find any curiosity in the distribution of the altered 
note, especially if the effusion is purulent ; for on account of the 
encapsulating tendency of adhesions any sort of pockets or com- 
partments may be formed. Therefore the percussion note should 
be most carefully practised. 

The physical signs of the three forms change in character as 
effusion becomes added to the dry pleurisy, and then increases in 
quantity. When the disease is fresh, the two affected surfaces 
rub upon each other in an unconfined way, and their condition is 
plainly heard. When adhesions exist, such movements are much 
decreased. If fluid is added to a new pleurisy, the physical signs 
are at first not pronounced. With a small amount of fluid and an 
absence of adhesions, the lung is floated somewhat higher than its 
usual level. But if the fluid is large in amount, and especially if 
the pleural surfaces become bound down adhesions, the lung tissue 
becomes hard, airless, and twisted out of its natural shape. The 
physical signs then become of much greater diagnostic value. 

Above the pleuritic area, and especially if there is a large or 
even a moderate effusion, the percussion note is clear, resonance is 
exaggerated, and often has the unchanging character that belongs 
to Skoda's resonance. As Ave approach the level of the pleuritic 
area or the surface of the fluid, the percussion note changes to 
dull, and over laro-e effusions it becomes flat. With such amounts 
of fluid the respiratory murmur becomes low and harsh, and finally 
may disappear. In the older children it may assume an amphoric 
character. One regular sign which we expect to hear in this 
disease is the characteristic friction sound. It is a fine, sharp, 
grating noise, heard on inspiration and expiration, and is caused 
by the opposing surfaces rubbing against each other. Adhesions 



286 THE MEDICAL DISEASES OF CHILDHOOD 

or large quantities of fluid may eliminate it, and thus produce a 
seeming exception to the rule. Its presence is diagnostic, but its 
absence is not. In other respects not too much reliance may safely 
be placed upon the results of auscultation. We may find bronchial 
or broncho- vesicular, diminished or puerile, breathing ; also, curi- 
ously enough, all these variations may at times be heard above or 
below the level of the fluid. The voice may be normal or bron- 
chophonic. The rales which regularly belong to the disease are 
fine crepitant ones ; any others belong to coexisting disorders. In 
a word, the auscultatory signs in infantile pleurisy may be con- 
firmatory, but outside of this have not much force. It is naturally 
understood that with increasing age children present signs that 
progressively approximate to those which the adult presents. 

A rarely encountered sign is asgophony. When it is distin- 
guishable, and where the lungs are not compressed by large quan- 
tities of fluid, it may be heard at the back on either side of the 
spine. 

Pain and dyspnoea are most apparent at first. The pain may 
vary or disappear after two days. When present in infants it is 
shown by the wrinkled and puckered face and repressed breath- 
ing. Even the youngest patients try to minimize the respiratory 
effort, and the attempts are often so plain as to be truly impres- 
sive. Older children show their distress by unwillingness to be 
touched, by a cramped posture, by shrill cries on coughing, on 
voluntary or involuntary movements. The dyspnoea depends 
upon the amount of pleuritic inflammation as well as the amount 
of compression of lungs and heart by fluid. At times it is very 
alarming, owing to the fact that on the left side the quantity of 
fluid may be so extreme as to squeeze and compress the lung, and 
float the heart out of its normal place into a twisted position in 
the right mammary region. On the other hand, effusion into 
the right side causes much smaller symptoms. The rule in in- 
fants, however, is that remarkable quantities of effusion are not 
common. The greater the amount of surface involved, the 
greater will the patient's efforts to restrain respiration be, with 
a consequent decrease in oxygenation. Likewise the greatest 
compression and displacement of lungs, heart, and the near great 
vessels will produce corresponding effects upon the circulation. 

The patient, as if fearing the pain that movement induces, is 
seen to lie unusually still. He prefers to rest upon the side 



DISEASES OF THE BRONCHI, LUNGS, AXD PLEURA 287 

which is diseased, because thereby he avoids a certain amount of 
movement. The affected side is apt to be fixed, and the diaphragm 
is allowed less movement than in normal conditions. In spite of 
the fact that the restrained breathing seeks to limit expansion, 
careful measurement will show a slight increase in the circumfer- 
ence of the chest due to the bulging out of the affected side. 
According to the degree of this bulging, there will develop a 



PULSE 


RESP. 


TEMP. 


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PULSE, RESP'RATION AND TEMPERATURE CHART OF PURULENT PLEURISY. 
OPERATION, DEATH. AGE, 8 MONTHS. 
pulse respiration temperature 

Fig. 44. 

tendency, most of all in large purulent effusions, to alter the 
contour of the intercostal spaces. 

The fever is not a constant one, and commonly has a distinct 
remittent form. As a rule it is high, especially when the pleuritis 
complicates another disease. The surface of the affected side has 
a higher temperature than any other part of the skin. 

The pulse follows the general temperature fairly well. In 



■M 



288 THE MEDICAL DISEASES OF CHILDHOOD 

young infants it may reach a maximum of 190 to 200. Usually 
it is thin and hard, excepting in cases of complication with acute 
lobar pneumonitis, where it is distinctly soft. But this is due to 
the predominating effect of the pneumonitis upon the vaso-motor 
circulation. 

The respiration is hurried and shallow, and, on account of the 
pain which each effort produces, does not follow the fever and 
pulse. Usually it is irregular ; but there is no predominating 
form of irregularity which one can crystallize into a general state- 
ment. A noticeable observation, however, is that the breathing 
varies from the thoracic to the abdominal type. In addition to 
the usual prostration, anxious feverish look, coated tongue, and 
scanty urine, we may, in some severe acute cases of a purulent 
type, have the added symptoms of pyemic infection, such as 
stupor or delirium, convulsions, unusual ranges of temperature, 
and finally collapse. 

In the cases where effusion is suspected, the diagnosis is to be 
confirmed by means of a large hypodermatic needle. Under careful 
antiseptic precautions there are almost no objections to this step. 
The most favorable position to make the puncture is in the sixth 
or seventh interspace in the posterior axillary line. In rare cases, 
when this test shows no fluid, the failure is due to the fact that 
the needle enters an adhesion. In such a contingency the point 
of the needle is not to be moved about, but the instrument should 
be entirely withdrawn and inserted anew. 

Complications. — The usual complications are those resulting 
from poor arterialization and hampered respiratory effort. Where 
the disease is of a purulent type we may encounter complications 
arising from a systemic infection. Also, where the purulent fluid 
is not liberated by operation, it sometimes burrows its way through 
the chest wall or through the lung tissue into a bronchus. The 
termination of this condition is generally favorable. Where pus 
forces its way through the chest wall there may supervene, as 
a result, a caries of the ribs with a possible extension to the 
vertebrae. 

Treatment. — In the first form, the treatment consists in the 
nursing, the regulation and modification of the food so that it will 
be most easily assimilated, and the control of pain. Considerable 
discomfort can be relieved by counter irritants, such as liberal 
applications of iodine. The actual cautery, if judiciously used, 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 289 

may be of a great value. With this agent, however, one must be 
careful, keeping in mind the ease with which a young child's skin 
becomes irritated. At times it may become necessary to use 
small doses of opium. It is desirable to see to it that the patient's 
strength is wisely conserved ; the use of stimulants may from 
time to time be indicated, and their quantity must be regulated 
to suit individual cases. 

Where effusion exists one must be particularly careful of press- 
ure effects and heart failure. Caution in allowing the patient to 
assume an erect position must be exercised. To facilitate absorp- 
tion, tonics and diuretics are to be given, the latter in liberal 
doses. For this purpose, plain or alkaline waters will be found 
of value. At times it may be necessary to aspirate the chest, in 
order to diminish the amount of fluid. This measure is of tem- 
porary value and does not prevent the return of the fluid ; if 
symptoms of pressure are very marked, the best plan of action is 
the same as in the purulent form : to open the chest wall with a 
free incision and secure sufficient drainage. The process of 
absorption by the economy is often so slow, that we are justified 
in operating and draining in a much greater number of cases than 
we now so treat. After the acute stage is past, the operation is 
even more desirable than before. 

The treatment of purulent pleuritis should resemble that of 
any pus cavity. The chest wall should be opened and thoroughly 
drained. It may be necessary — I believe it is practically always 
desirable — to resect a rib. Thereby one obtains a more thorough 
drainage. 

As the patient begins to convalesce, he should be most carefully 
treated and nursed so that every opportunity for the regain of 
health and strength may be improved. Even under favorable cir- 
cumstances he is apt to suffer for a long time on account of com- 
pression of the lung and changes in pleural surface. 

Prognosis. — In primary pleuritis, the prognosis is usually 
favorable ; but when the disease arises by extension, the outlook 
is more serious. In almost all cases the original infecting disease 
is apt to be made severer by the lighting up of the pleuritis with 
its peculiar disabilities. 

Differential Diagnosis. — The main signs are the evidences of 
pain, the dull note over the pleura, and the flat note over the fluid. 
When this much is distinguished and there are besides no rales or 



290 THE MEDICAL DISEASES OF CHILDHOOD 

very few rales at the margin of the affected area, the diagnosis is 
more nearly certain. With fluid the character of the bronchial 
breathing is modified and friction sounds*are absent. The distinc- 
tion between a purulent and a non-purulent effusion may be made 
from the more virulent character of the symptoms in the former, 
but most of all by aspiration. From a pneumonitis one may dis- 
tinguish pleurisy with effusion by the former's high temperature, 
greater resulting prostration, and more acute course ; by the 
pleurisy's greater area of dulness or flatness, and the changing 
location of this flatness, as well as the absence of many reliable 
auscultatory signs. 

Chronic Pleurisy 

Causes. — A chronic form of inflammation of the pleura exists 
more often than is generally believed. When one considers the fer- 
tile causes that may produce it, this conclusion seems inevitable. 

Lesions. — After an acute pleuritis it is practically impossible 
to lose all trace of the changes in the involved tissue. The pleura 
remains thickened and heavy. Frequently the thickening exists 
in more or less scattered areas, but sometimes the process involves 
the whole pleura. In these latter cases a partially uniform con- 
dition exists ; here and there the changes are especially marked, 
so that one is apt to find spots where the characteristic pliability 
and functions are quite absent. The hypertrophied portions are 
covered with large endothelial cells in great numbers. There is 
an increase in the connective tissue, which on account of the 
marked growth of the blood-vessels has no natural tendency to 
decrease. The pulmonary and costal membranes are bound 
together by strong, firm adhesions which are apt to be surpris- 
ingly large in number. These adhesions become thoroughly 
organized, contain blood-vessels, and are sheathed with endo- 
thelium. 

Symptoms. — The symptoms are such as commonly escape 
connection with the lesions and often are attributed to quite a 
different cause. On inspection the chest is seen to expand irre- 
gularly ; and in marked cases the difference between the two 
sides is so great as by comparison to make the affected part seem 
stationary, while the rest of the chest exerts unnaturally intense 
efforts. Percussion gives a dulled note which in severe cases 
may become almost flat. The ear, on auscultation, hears the 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 291 

breathing as if from a distance ; and a few moist rales are often 
present in scattered areas. When the lung is free, one is apt to 
make out all the signs of emphysema, which on account of the 
inactivity in certain parts is bound to develop in others. Some- 
times there is a tenderness of the chest which is liable to become 
in the face of an irritant an acute pain. Where the chest Avails 
are bound down, there may be considerable deformity. With 
this goes an imperfect aeration of the lung tissue with the conse- 
quent proneness to acute inflammations. For trifling causes the 
patient may have a rise of temperature that is apt to puzzle the 
attending physician. This may be unattended by a correspond- 





Fig. 45. — Chronic Pleurisy. X 25. 



ing rise in the respiration- and pulse-rate, excepting in those cases 
where an appreciable acute sickness supervenes. There is a great 
variation in the appearance of the patients, some showing at first 
sight hardly any physical deterioration, while others are clearly 
exhausted, ready to lapse into a serious decline. There is a con- 
stant disposition to respiratory irritations which may easily start 
into active disease. There is a chronic hacking cough that is 
hard to quiet, returning on slight provocation. 

Treatment. — The treatment of building up the general health 
by exercise and tonics is of most use. Such tonics as the com- 
pound syrup of hypophosphites or cod liver oil in a malt prepara- 



292 THE MEDICAL DISEASES OF CHILDHOOD 

tion may be recommended. Exercises which tend to expand the 
chest and stimulate the lung tissue should be carefully and vigor- 
ously employed. At the same time it is wise to counsel the con- 
tinued practice of athletic sports and games as well as every means 
that can promote the general health and strength. Living in 
high latitudes, on account of the increased expansion of lungs 
which follows, is often of decided value. By such simple means 
a satisfactory improvement can be brought about which requires 
no more than a continued regulation of all the details of daily 
life for its perpetuation. Much patience may be required ; but 
the result will justify the outlay of effort. 

Atelectasis 

By this name is meant a condition in which parts of the lung 
become entirely deprived of air ; as a result the unaerated portions 
collapse, and when once they are in this state their tendency is 
not to resume their function. Any part — much or little — of a 
lung may be involved, and at any age from birth up to adult life. 
As a rule, however, we meet this condition in infancy and most of 
all in weak babies. 

Causes. — The existence of marked physical weakness is the 
main predisposing, and often the main active factor in the produc- 
tion of atelectasis. Whether this weakness is congenital or the 
result of disease makes little difference. The prematurely born 
child may equally with the syphilitic run the gauntlet of atelec- 
tasis ; or the tubercular, the rachitic, the poorly nourished baby 
may likewise be afflicted. Following out this general idea we get 
a conception of the causes which work at any period ; for even in 
the face of an active cause of atelectasis, there still must be the 
foundation of noteworthy exhaustion. Such active causes might 
be the occlusion of a bronchiole in the course of a local disease by 
a plug of mucus, the exhaustion of the residual air sometimes 
resulting from the prolonged spasm of pertussis, the viciously 
congestive action of severe cardiac and pulmonary disease, tumors 
of the chest and abdomen, deformities of the chest, and foreign 
bodies in the lung, all of which may exert so much pressure upon 
an area of the lung that the air is forced from it. One should 
keep in mind those rare and interesting cases of nervous disorders 
where, on account of paralysis of the pneumogastric nerve or dis- 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 293 

ease of the respiratory centre, the act of breathing becomes ex- 
ceedingly difficult and progressively less efficient. Naturally 
such disability can act just as surely in the long run as the more 
acute obstructions mentioned above. In case the obstructions are 
quickly removed the lung naturally seeks to resume its form and 
function; but where the relief is too long delayed the harm is apt 
to be irreparable. 

Lesions. — If the atelectasis occurs at or immediately after birth 
and before the lung has been well expanded, one fails to find any 
inflammation — merely rather hard, flesh-like tissue that has a 




Fig. 46. — Atelectasis with Compensatory Emphysema. X 43. 

somewhat darker color than liver. The longer the tissue remains 
unaerated, the harder and less lung-like the affected part becomes. 
In children of greater age, where the collapse has been caused by 
obstruction, one is apt to find more or less bronchitis scattered 
here and there. The collapsed areas will be found to be con- 
nected with the inflamed tubes and to radiate in a fan-like fashion 
from them. These patches are, of course, much heavier than 
normal lung tissue — so much so, in fact, that they cannot float 
in water. On account of the uselessness of these portions, the 
neighboring areas of the lung must — or at least try to — make 
up the deficiency. In consequence they become plainly emphy- 



294 THE MEDICAL DISEASES OF CHILDHOOD 

ematous. This lack of balance in the relation of parts is a fruit- 
ful source of congestive disorders, which in turn may be followed 
by any manner of lung disease. 

Symptoms. — The symptoms in a fairly well-marked case are 
impressive. The child is restless, somewhat cyanosed", and suffers 
from dyspnoea. The face has a sunken appearance, the nostrils 
work convulsively, the breathing is shallow, and the chest wall 
under the load of atmospheric pressure is apt to be retracted. 
The rate of respiration is hurried and irregular, the temperature 
is very slightly elevated or normal, or in serious cases subnormal. 
The ordinary relation in rapidity between pulse, respiration, and 
temperature may be quite lost. 

Over the atelectatic area the respiratory murmur is faint or 
imperceptible. If this area is not too deeply located, there is 
dulness on percussion. If emphysema, bronchitis, pneumonitis, 
cardiac or intestinal disease be present, the characteristic symp- 
toms will naturally manifest themselves. 

Treatment. — There is no especial treatment except the wisest 
possible regulation of all the details of food, bathing, clothing, 
and general management. As these cases are very weak and 
exhausted, one has opportunities for the exercise of much resource, 
ingenuity, and patience in the attempt to develop as far as possi- 
ble the little patient's vitality. Stimulants and tonics must be 
employed, and their use will be directed and regulated by the 
varying necessities of individual cases. 

Prognosis. — The prognosis is bad. 



Emphysema 

Causes. — This condition consists in an abnormal dilatation of 
the air-vesicles of the lung, with a consequent increase in the 
amount of contained air. Although this amount of air is often 
large, the lung does not get the benefit of a large amount of oxy- 
gen, for the walls of the air- vesicles are so constantly kept on 
the stretch that they lose their tone and resiliency. In conse- 
quence, their functional activity suffers. The marked pliability 
of the tissues in childhood makes the occurrence of an attack of 
emphysema very easy. Indeed, it is very probable that in all the 
sicknesses which involve severe spasms of coughing, there is more 



DISEASES OF THE BRONCHI, LUNGS, AND PLEURA 295 

or less dilatation of the air-vesicles. In addition, the barrel- 
shaped chest of the infant by its very form invites emphysema. 

On the other hand, if it is easy for these little patients to 
acquire this disorder, it is likewise easy for them, excepting in the 
case of the so-called substantive form, to rid themselves of it. On 
the return of a fair amount of vitality, the lung tissue resumes its 
usual anatomical condition, and its function reestablishes itself. 
In children one meets with three forms which, on account of their 
manner of occurrence, are generally designated as vesicular, inter- 
lobular, and substantive emphysema. 




.fry , ^ _ 

Fig. 47. — Emphysema. X 31. 



When a child, on account of the disability of some of the 
bronchi or bronchioles, or when a part of a lung has been ren- 
dered incapable of operation, attempts to perforin the usual re- 
spiratory motions, the undisturbed portions of the lung are forced 
temporarily to do more than their share of work. As a result 
they become stretched out and dilated during the progress of the 
impeded breathing. This is called vesicular, or compensatory, 
emphysema. 

When the expiratory efforts are really severe, when a great 
strain is put upon the air-spaces, their walls are apt to break. 



296 THE MEDICAL DISEASES OF CHILDHOOD 

The air rushes in, making the cavities progressively larger with 
fresh exacerbations of the exciting cause. Thus the air may 
work its way in all directions through the interstitial tissue of 
the lungs. It may even find an outlet through the pulmonary 
pleura into the neck, mediastinum, face, or other parts of the 
body. This, the so-called interlobular form, may arise from a 
severe pneumonitis or broncho-pneumonitis, from whooping-cough, 
asthma, or laryngitis. The lesions are more firmly seated than in 
vesicular emphysema, and when the disabled parts are large in 
extent may persist for years. 

In substantive emphysema one finds the most serious cases. 
Not only the form, but also the substance, of the space walls may 
be changed. Indeed, the alteration in the form may not be very 
marked, the amount of dilatation may not be very great, but there 
is a slow but sure laying down of connective tissue in the walls of 
the air- vesicles, which renders them practically immovable. This 
is not apt to occur excepting in older children, especially those of 
a vicious physical disposition. 

Lesions. — In the mildest forms the lesions, outside of the 
changed shape of the air-spaces, are barely noticeable. In the 
severe forms the whole lung may be increased in size. The small 
bronchi may be thickened, and here and there along their course 
one may see spots of pneumonitis. There may be much mucus 
secreted, or mucus mixed with small quantities of pus. The air 
spaces are often affected in groups, so that the whole appearance 
of the lung is irregular. The diseased air-vesicles have ruptured, 
thickened walls which, when the chest is opened, do not collapse. 
In such cases disorders of circulation are apt to occur ; but as 
there must be some fairly severe disease to cause the emphysema, 
one is not positively sure whether the original disorder or the 
emphysema was the cause of the imperfect circulation. 

In the severest form of emphysema, one notices a tendency to 
the production of connective tissue in small, scattered areas. The 
walls of the air-vesicles, of the small bronchioles, and of the arte- 
rioles are thickened and slightly rigid, but irregularly so. Some- 
times one can notice a slight proliferation of the endothelial 
cells. 

Symptoms. — In the mildest cases practically no symptoms 
reveal themselves to the examiner. The infantile chest, being 
naturally barrel-shaped, is apt to assume the appearance of being 



DISEASES OF THE BROXCHI, LUXGS, AXD PLEURA 297 

afflicted with dilatation of the pulmonary elements. But in the 
more strongly marked cases there is a hyper-resonant note on per- 
cussion. Expiration is apt to be long drawn out. There may be 
some of - the auscultatory signs of a sub-acute bronchitis, and, in the 
severest cases, of a slight pneumonitis. But even where these are 
absent, the respiratory murmur lacks the clear, even character of 
health. Where deformities occur, such as those of the spine or 
pleuritic adhesions, their presence will help to define and empha- 
size the symptoms. Moreover, one may expect congestion of any 
viscus or the skin. As the disease is apt to accompany conditions 
of defective strength, one is apt to see such signs of malnutrition 
as rounded shoulders and bent backs, depressed surfaces over the 
poorly aerated apices, lower ribs that are bent out, retracted upper 
abdominal region, and an indefinite number of characteristics that 
go with a run-down and worn-out physical state. 

The patient on slight provocation complains of dyspnoea, less 
frequently of asthma and rarely of pain and soreness. He shows 
a notable liability to pulmonary diseases and, if they attack him, 
he resists their inroads with poor success. 

Treatment. — The treatment, when there is an antecedent dis- 
ease, consists in no additional measures until its acute symptoms 
have ceased. Then, and as the surest means of recovery, every 
attempt must be made to build up the patient's health in every 
possible direction. The diet, largely nitrogenous, should be as 
hearty as his digestion permits. If the climate in which he lives 
is trying, he should be removed to a locality which is not too 
high, where the air is clear, and where there are no extremes of 
temperature. Tonics, such as nux vomica, the organic prepara- 
tions of iron, hypophosphites, and — where the digestion is good 
— small doses of cod liver oil, will be found of use. One must 
be careful not to permit violent exercise. 

Prognosis. — Where the disease is mild and merely compensa- 
tory, there is a good likelihood of complete recovery. This is 
especially true when the pathological changes have not existed for 
long. However, when the disorder has persisted for long periods 
of time, especially in the serious cases, such as the substantive 
form, it is unreasonable to expect a complete recovery. 



298 THE MEDICAL DISEASES OF CHILDHOOD 

Gangrene of the Lungs 

Gangrene of the lungs, while seen quite often in adults, espe- 
cially in exhausted patients, is rarely encountered in children ; in 
infants it is barely liable to occur. It is in its final aspect a 
senile condition rather than a disease. It means the quick suck- 
ing up of the very life of the affected parts, and their invasion, as 
so much inert organic matter, by pus-forming bacteria. There 
is no physiological reason why children should be more exempt 
than adults from its attacks ; but in most cases of profound loss 
of vitality children will succumb before the stage of gangrene 
supervenes. 

Causes. — In the progress of some primary disorder the lung 
tissue becomes broken down. This primary disease may be one 
of the inflammations of the lung coupled with a weakened cardiac 
condition. A rational reason for the starting up of a gangrene is 
a wound of the lung which admits putrefactive bacteria or the 
introduction by any means of a foreign body. In fact, any 
method of bringing pathogenic micro-organisms to a weakened 
lung area, especially in the presence of a general physical impov- 
erishment, is sufficient to bring about the disease. In addition, 
any interference with the integrity of the arterioles, which is 
fortunately rare in infancy and childhood, can by withdrawing 
the local means of nourishment cause the area to degenerate and 
break down. 

Lesions. — When the process has once begun, the affected por- 
tions become hard, dry, and discolored. The surrounding area 
takes on a low form of general inflammation, involving the paren- 
chyma of the lung, bronchi, or pleura. A fatty infiltration makes 
its way through the margins of the gangrenous portions, the cen- 
tral parts of which begin then to soften and break down. The 
normal color fades and changes to yellow and green, and finally, 
when decomposition has fairly begun, an intensely offensive odor 
develops. At this time the various bacteria of putrefaction may be 
found in huge swarms. No one form seems to have an inevitable 
predominance, either in the production of the diseased condition, 
or as a disposing factor in influencing the course of the sickness. 

The process may be limited to a single focus, may be scattered 
in many different parts, or may invade the whole lung. Which 
course it will take is decided by the question of general and local 



DISEASES OF THE BROXCHL LUNGS, AXD PLEURA 299 

nutrition. As a result of these differences in location we are in 
the habit of classifying the forms as circumscribed and diffuse. 
In the first a single spot may be affected, while the rest of the 
lung remains fairly normal. It is possible that this spot after 
breaking down may be eliminated, with the result that the cavity 
becomes filled with connective tissue which contracts and leaves a 
healthy scar. In the second form the whole lung is disintegrated, 
it may even become fluid, and then the possibility of recovery is 
past. When the necrotic fluid, containing products of decompo- 
sition and bacteria, is able, either by its corrosiveness or by the 
weakness of the tissues, to make its way into different parts of the 




Fig. 48. — Gangrenous Abscess of Lung. X 235. 

lung, direct contamination follows. If this process extends to a 
blood-vessel it continues its course without interruption, the 
walls are destroyed, and a more or less serious haemorrhage results. 
In the same way a bronchus may be perforated ; in this case, how- 
ever, the patient experiences some relief because the products of 
necrosis thus find a free exit. Such a situation is far preferable 
to the one in which the decomposition eats through the lung to 
the pleura, thereby starting a purulent pleuritis. 

Symptoms. — Even before the gangrene fully begins, the 
symptoms of the primary disease become exaggerated. In addi- 
tion the patient plainly suffers from extreme prostration. The 



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300 THE MEDICAL DISEASES OF CHILDHOOD 

loss of flesh and strength is rapid, the face has an anxious, 
worried look. The temperature is irregular and remittent, the 
pulse is rapid, thin, and irregular. The picture is such as to 
force upon one's mind the idea of purulent process. If the 
disease is far advanced, the destruction of tissue may be suffi- 
ciently extensive to give the signs of a pulmonary cavity. The 
frequency of this last condition is in inverse ratio to the youth of 
the patient ; for the younger the child, the less can he resist the 
invasion of gangrene. Finally, one characteristic sign should be 
mentioned : there is a very foul odor about the patient, which ema- 
nates mostly from the breath, but also from the body as well. 
I well remember a case in a boy of ten years, where this odor 
could be discerned at a distance of from twelve to fifteen feet. 

Treatment. — There is no specific and successful treatment. 
The regular course is to give inhalations of disinfectants, such as 
terebene, creosote, thymol. Their value is doubtful, for the 
process is too intense both in its aetiology and its course to yield 
to such slight remedies. All that one can do is to give tonics 
and stimulants while in every way conserving the patient's physical 
resources. 

Prognosis. — The prognosis is bad. 



CHAPTER XVI 

DISEASES OF THE HEART 

Functional Cardiac Disorders 

In infants and young children functional disorders of the heart 
are few and not very important. All those which we may desig- 
nate as subjective are, from the very fact of youthful immaturity 
and imperfectly conscious mental conditions, ruled out. There 
would then be left variations of rhythm only, such as tachycardia 
(rapid heart action), brachycardia (slow heart action), and ar- 
rhythmia (irregular heart action). 

The ^etiological factors are common to all, and for the most 
part are grouped about the central fact of impaired nervous con- 
trol. In very young babies this is a common condition, due 
largely to a naturally deficient coordination. Evidences of this 
one sees every day in the aimless spasmodic movements of arms 
and legs, in the temporary lack of control of the eyes. In a simi- 
lar way, close observation will show temporary defective nervous 
control of the heart action. 

In older children this state of things is naturally brought 
about by nervous shock and strain, by diseases of the brain and 
cord, by cardiac and pulmonary disease, b} r inherited weakness or 
sickness, during convalescence after the acute fevers, by diathetic 
and wasting diseases. 

The neuroses have no characteristic physical signs which are 
common to all. Tachycardia is often associated with a strong 
apex impulse, as brachycardia — although less frequently — is 
with a weak one. As a rule, all that there is to be found out 
may be ascertained by inspection or palpation. Auscultation 
will occasionally and in very weak cases reveal a murmur which 
is often hadinic ; but it is possible that such a sign is coincident 
with the neurosis, not dependent upon it. 

It is best to regard all these cases, unless there are concomi- 
tant reasons for alarm, as of comparatively little importance. 

301 



302 



THE MEDICAL DISEASES OF CHILDHOOD 



Not only does organic heart disease not develop from them, but 
also there is no particular reason for believing that the neurosis 
will persist for a long time, most of all if the general condition 
and circumstances of the patient are good. If diet, exercise, and 
moral control are good, the outlook is excellent. 

Myocarditis 

Myocarditis is an inflammation of the heart substance which 
begins with the vessels and extends to the muscular fibres. Then 




Fig. 49. — Normal Heart Muscle. X 220. 



it may proceed inward or outward, involving the endocardium, or 
pericardium. It may occur in intra-uterine life or early infant 
life, and may extend indefinitely into childhood. 

Causes. — The disease usually appears as a complication or 
sequel of endocarditis, pericarditis, diphtheria, scarlatina, pyemia, 
septicaemia, phosphorus poisoning, pernicious anaemia, and other 
infectious or non-infectious diseases. There is reason for believing 
that severe wasting diseases may bring about the atrophic changes 
of the so-called parenchymatous form. 



DISEASES OF THE HEART 303 

Lesions. — According to the pathological changes one may 
divide the cases into parenchymatous, interstitial, and purulent 
forms. The first-named is characterized by a loss of the proper 
conformation of the muscular fibres, which degenerate and become 
infiltrated with granular matter. The full color fades and 
becomes dull and heavy. In the insterstitial form the process 
assumes a chronic character. The muscular fibres becomes 
irregularly infiltrated with small cells, and the normal tissue may 
gradually be replaced with new connective tissue which is apt to 




Fig. 50. — Parenchymatous Myocarditis. X 80. 

be unusually hard and inelastic. In the purulent form bacteria 
find a lodgment in the weakened spots. These areas then slowly 
break down, forming larger or smaller abscesses. They may 
extend and break in any direction, or they may slowly heal, the 
pus being absorbed while the empty space becomes filled with 
granulation and connective tissue. 

In that form of degeneration which is commonly called "fatty," 
the muscular fibrillae are infiltrated with droplets of fat. They 
may vary in quantity from a hardly appreciable amount to so 
great a number that the characteristic appearance of the tissues 
is clouded. In the fatty myocarditis that occurs in pernicious 



304 THE MEDICAL DISEASES OF CHILDHOOD 

anaemia and phosphorus poisoning the color of the organ may be 
changed to light reddish yellow, and its consistency may be soft 
and yielding. 

Symptoms. — In infants the symptoms are very obscure, 
especially as the disease almost never occurs alone. There is no 
murmur to be expected unless the spread of the lesions is very 
great, and even then there is apt to be some concomitant disorder 
which would likewise explain it. One should, however, expect a 
disturbed heart action, with weak and irregular pulse, fluctuating 




Fig. 51. — Interstitial Myocarditis. 

temperature, dyspnoea, cyanosis, and prostration. The symptoms 
are all the more obscure because the disease may begin very early 
and in a very gradual and insidious way. 

Full knowledge of the disease is usually obtained on post- 
mortem section. 

Treatment. — All that one can do for these cases is to husband 
and nourish the resources of the patient and answer the demands 
which the symptoms make. In doing this digitalis should be 
excluded, or at most should be used with great caution. The 
prognosis is bad, not only on account of the disease itself, but also 



DISEASES OF THE HEART 305 

because the conditions with which it occurs are so serious and 
exhausting. 

Acute Endocarditis 

An inflammation of the endocardium, the lining membrane of 
the heart, is in childhood a common and very disturbing disease. 
The least informed parent has heard and is deeply impressed by 
the dangers of it. On the whole, this fear is not misplaced, for 
even if the sickness does not result in death, nevertheless it so 
seriously affects the growing body that in many cases the most 
rigorous attention will often be unable to atone for the damage. 

Causes. — One of the curiosities of endocarditis is its occur- 
rence before birth. Xaturally, this is a rare condition. When it 
so exists it is evidently caused by pressure on the pulmonary 
valves, and thus affects the right heart. It may likewise be due 
to maternal or inherited disease ; but occasionally one will search 
in vain for the cause which has set the process in motion. A 
peculiarity of the disease at this time is the preference which it 
has for attacking the right heart. This is doubtless due to the 
peculiar state of development in which the heart and lungs find 
themselves. When the disease is not congenital, it is rarely seen 
during the first two years of life. Then it may accompany 
chorea, pulmonary, and septicemic or pyaemic diseases. As 
instances one may cite cases of purulent inflammation of the um- 
bilicus, the bones, and the kidneys. It may be due to diathetic 
diseases, syphilis, and tuberculosis. The commonest causes, how- 
ever, are scarlet fever and rheumatism. One constantly sees 
the connection in patients suffering from the latter disorder, but 
infants, since they do not seem to be often attacked by rheuma- 
tism, form a partial exception to the rule on account of their age. 
However, when young children do have rheumatism, they are 
most likely to suffer from a complicating endocarditis. 

The belief in the bacterial origin of endocarditis is obtaining 
a wider hold with successive attempts at forming a rational aeti- 
ology. The proof of the theory is as yet incomplete, and there- 
fore it is advisable to do no more than mention it. 

Lesions. — In this disease the endothelial connective tissue 
becomes brighter in color, most markedly so at the edges of the 
valves where the inflammation oftenest occurs. The capillaries, 
with which the tissue is but poorly supplied, become enlarged and 



306 THE MEDICAL DISEASES OF CHILDHOOD 

develop in every direction. The valve increases in size, and be- 
comes succulent. The products of inflammation, as seen in a dis- 
order of the mucous membranes, are scanty. On the other hand, 
the connective tissue cells and the basement membrane are swollen 
and hyperplastic. 

In the severer cases the sub-endothelial connective tissue, 
besides being swollen, becomes infiltrated with new proliferating 
cells which extend to the membrane below. The surface may 
then be roughened and studded with nodules. Also the cells may 
proliferate, the nodules may become eroded, w T ith the resulting 




Fig. 52. — Valve in Acute Endocarditis. X 25. 

formation of ulcers. On these nodules and ulcers fibrin collects 
as on a foreign body ; the resulting formations, consisting of gran- 
ulation tissue covered by fibrin, constitute vegetations. These 
vegetations may vary in shape from minute elevations to much 
larger growths having a broad base. While this process is going 
on, the newly formed vascularization tends to bring about an exu- 
dation of fibrin. Masses of this material, whatever their origin, 
may be rubbed off, and are then carried in the blood current to 
any part of the body to form thrombi and emboli. Under the 
microscope these masses show a mixture of proliferated cells. 



DISEASES OF THE HEART 307 

The inflammation may extend all over the endocardium, and 
«ven penetrate into the inner coating of the arteries. 

Symptoms. — The heart action, as usually seen, is rapid and 
violent, especially in young children, whose thin and soft chest 
walls most rapidly lend themselves to transmission of the motion. 
For this reason, partly, the great veins are likewise easily seen to 
be engorged. At the same time one may notice that' the apex 
beat is displaced. On palpation one detects the irregular heart 
action, as well as a thrill, which is often of much significance. 
One may recognize the failing force of the apex impulse as well 
as its diffusion. 

On account of the conformation and relations of the chest 
walls, the soft, blowing mitral systolic murmur which occasionally 
comes with this disease is, as a rule, found to be transmitted to 
the left. Generally this, when present, is distinctly heard, but 
with this distinctness comes a liability of confusion with other 
murmurs, mainly hsemic. The second pulmonic sound is com- 
monly exaggerated, on account of the inevitable pulmonary con- 
gestion ; or as the result of the impeded circulation one may hear 
a secondary murmur at the tricuspid valve, and sometimes — but 
much more rarely — at the aortic. Murmurs so located are rarely 
anything but secondary. All these facts will naturally be modi- 
fied by the intensity of the cardiac inflammation as well as by 
complicating signs in other organs. 

The general symptoms are neither many nor always quite re- 
liable. There may be plain evidence of pain in the chest, so that 
even younger children, by their unconscious motions, locate it 
with a fair amount of distinctness. Handling the patient in any 
but the gentlest way is apt to call forth such signs of distress that 
the attention is necessarily called to the unusual manifestations. 
There may be coughing, especially if the disease is associated with 
a dilated heart. Dyspnoea is one of the most constant symptoms 
which is always disturbing and sometimes startling. It may be- 
gin at the outset, but is most apt to appear at the time of intense st 
inflammation. At the height of the attack, when it is most alarm- 
ing, it may bring with it as a potent accompaniment varying 
degrees of cyanosis. Then, in very severe cases, coma may super- 
vene, and, as a frequent result, death comes. On section the heart 
is found to have stopped in diastole. 

The pulse at first is full and rapid ; as the disease progresses 



308 THE MEDICAL DISEASES OF CHILDHOOD 

and weakness becomes more pronounced, it grows smaller, irreg- 
ular, and dicrotic. The variations in rapidity may be great ; 
indeed, the whole character of the pulse may, under the many 
circumstances of the disease, change to an appreciable degree. 
The temperature is atypical, rarely running very high, and may 
be somewhat remittent. At serious stages of the disease it some- 
times shows a tendency to fall below normal. 

The respiration is rapid and irregular ; often the child stops 
to catch his breath, as though oppressed. The difficulty in breath- 
ing is especially apt to follow very high and very low tempera- 
tures. At such times of strain the tendency toward congestion 
of any part of the body is unusually great ; even under ordinary 
circumstances it is great enough to cause various symptoms, which 
are referable to the part involved. Thus where the peritonaeum is 
concerned, there would be ascites ; where the stomach is attacked, 
there would be nausea, vomiting, and disturbances of digestion ; 
in the kidneys there would be the symptoms of congestion, with 
a small amount of urine holding a little albumin and a minute 
quantity of casts. It is especially common to have an obstinate 
bronchitis, which at times persists in spite of almost everything 
that the attendant may do to check it. The vegetations on the 
valves, or fragments of them, may be swept away from their loca- 
tion, and thus form embolisms in the kidneys, lungs, brain, or 
other organs. Appropriate symptoms would, of course, then show 
themselves. 

Treatment. — The treatment, after all is said, is mainly symp- 
tomatic. Naturally, if there is an antecedent or complicating 
disease, such as rheumatism or scarlet fever, that must be vigor- 
ously treated. For the endocarditis, the first thing to do is to 
secure absolute quiet and rest of body and mind. And one must 
remember that children are equally as, or even more, prone to 
have worries of mind than adults. The diet should be fluid, 
easily digestible, and not given in too large amounts. For the 
pain it will in most cases be necessary to give opium, excepting in 
infants, who may often be quieted with sodium bromide in fairly 
large doses. In either case the drug must be prescribed in large 
enough amount to produce its characteristic effect and the desired 
relief. For the weak heart action one may use with success re- 
peated doses of digitalis, nux vomica, and sometimes alcohol. 

All through the disease, lasting from a few days to a month, 



DISEASES OE THE HEART 309 

one should keep in mind its exhausting nature. Children very 
soon show the effects of it, and become markedly weak and anae- 
mic . The attendant has the opportunity of showing, in his ability 
to cope with these changing circumstances, much judgment and 
fertility of resource. 

Prognosis. — The prognosis for attacks of moderate severity is, 
on the whole, good. Those which are characterized by a marked 
intensity of the inflammatory process have little chance of life. 
Most children recover, but they remain for months weak, and 
liable to a recurrence of the disease. Repeated attacks become 
more and more serious, for with each one the organic changes in 
the heart become progressively more pronounced. 

Differential Diagnosis. — Often the disease, especially at the 
beginning, may be hard to recognize. The heart murmur, which 
is so characteristic of the chronic disease, is commonly absent. 
Also, the wear and tear of the sickness bring on a rapid invasion 
of anaemia which commonly gives a haemic murmur. This fact 
should constantly be kept in mind, so that the sound may not be 
diagnosticated as an organic murmur. The main elements of 
endocarditis to keep in mind are the cardiac pain and distress, 
the violent heart action with the frequent accompaniment of a 
thrill, the marked dyspnoea, and the possible cyanosis. The only 
disease that is apt to cause confusion is an acute pericarditis. 
Here the peculiar friction sound, the possible effusion, pericardial 
swelling, and likelihood of cardiac displacement are sufficient to 
show the true diagnosis. 

Chronic Endocarditis 

This disease is encountered in comparatively large numbers ; 
and in many ways it is intensely interesting. As much as any 
other, and more than most other diseases, it has a widespread 
influence upon the child's entire life. It may produce any amount 
of disability, it may gather in its train an endless procession of 
direct symptoms and complicating disorders. More than most 
diseases it calls for a careful consideration of all its possible 
developments. 

Causes. — The causes which produce it do not differ much 
from those of the acute form. In fact many cases are merely 
extensions of a previous acute attack. In the vast majority of 



M 



310 THE MEDICAL DISEASES OF CHILDHOOD 

cases the endocarditis accompanies or follows rheumatism ; in 
other patients all that one can find is a history of chorea, or 
possibly of some bone or microbic disease. The varieties of foetal 
or congenital endocarditis have been described on pages 41-43. 

Lesions. — The lesions are the natural development of those 
of the acute form. The endocardium of the cavities and the 
mitral valve is oftenest involved ; next in frequency comes 
involvement of the aortic valves. The tricuspid or pulmonary 
valves are much less commonly attacked. The surface of the 
endocardium may have the little smooth beads or the large 
eroded vegetations that exist in the acute form. The main addi- 
tional features are the marked production of connective tissue, 
the destruction of the endothelium, and some infiltration of cal- 
cium salts. The changes in the endocardium cause the valves to 
be twisted, puckered, shortened, and heavy. The milder cases 
show little interference with the smooth surface of the endocar- 
dium ; the severe cases, on the other hand, are the ones in which 
roughening and distortion occur. 

Symptoms. — The objective symptoms permit, in the attempt 
properly to interpret them, of the keenest exercise of observation 
and logical deduction. In fact there is no disease in the exact 
recognition and treatment of which these faculties are of greater 
use. For in chronic endocarditis the effects may show themselves 
in any part of the body and involve widely separated functions. 
Frequently the abnormal conditions come about in an indirect 
way, and it is only by tracing the pathological conditions to their 
logical causality that one reaches a fairly positive result. Many 
a time a child, with few or no direct objective symptoms of endo- 
carditis, may begin to complain of a disorder which is seemingly 
far removed, and only after careful examination is the fact of a 
long continued inflammation of the endocardium firmly estab- 
lished. This, when one takes into consideration the widespread 
effects of such a disease, is not at all remarkable. For when the 
integrity of the valves is impaired, an abnormal strain is put 
upon certain parts of the heart muscle, with the result of a 
varying amount of dilatation or hypertrophy or both. Or the 
minute structure of the muscular elements may be affected so that 
some degree of myocarditis may exist. In other cases the lining 
of the arteries may be injured so that the child will show the 
symptoms of endarteritis. In still other cases the tone of the 



DISEASES OF THE HEART 311 

arterial vessels will be altered, the blood pressure will be abnor- 
mal, and then the step to a congestive inflammation of the kidneys 
is an easy one. In fact all the viscera may in an analogous 
fashion be influenced so that corresponding results will show 
themselves. Thus the lungs may deteriorate to a condition of 
chronic pneumonitis with patches of emphysema, the stomach 
may fall into a state of troublesome irritability, the liver, spleen, 
and even the brain, may give their respective signs of pathological 
disturbance. In short, there may be a general venous congestion 
as well as an irritation of the mucous membranes that is multiform, 
elusive, and wearying to both patient and physician. 

The main thing, however, is the endocarditis itself. This 
may be of any degree of severity and may continue for a variable 
time, according to its intensity and the patient's power of resis- 
tance. Outside of this it shows itself principally in various 
murmurs, caused by stenosis or insufficiency of the valves. Such 
a narrowing of the orifices (stenosis) does not permit the requisite 
quantity of blood to pass, and naturally the chamber from which 
it flows is overcharged with its contents. Insufficiency results 
where the muscular tissue as well as the valves is in such a con- 
dition that when the blood has passed, the orifice is not entirely 
closed ; therefore some of the blood regurgitates into the cavity 
from which it came. It is possible by hypertrophy of the heart- 
wall or dilatations of the cavities, which are great enough to 
equalize conditions, that no effects of pathological changes may 
be apparent. Such a fact is spoken of as compensation. Again, 
this artificial equilibrium may, by an acute attack of rheumatism 
bringing with it an exacerbation of the endocarditis, or by such 
vicious agents as failing vitality, no matter what the cause may 
be, fail ; then the patient will immediately show the symptoms 
of cardiac trouble, generally by one or more of the ordinary 
murmurs. 

Mitral insufficiency is very frequently seen in childhood. It 
gives a systolic murmur, heard most plainly at the apex and 
transmitted to the left. Unlike some other murmurs, it is nearly 
always constant, especially if preceded or accompanied by rheu- 
matism. Here, on account of the insufficiency, the blood regur- 
gitates during systole from the left ventricle into the left auricle. 
As a result, the left ventricle is hypertrophied, or dilated and 
hypertrophied. The pulse is full. 



312 THE MEDICAL DISEASES OF CHILDHOOD 

Mitral stenosis is indicated by a systolic or presystolic mur- 
mur. The presystolic murmur is heard over a small area about 
the location of the apex impulse. When there is a systolic mur- 
mur it is transmitted to the left, but not so distinctly as the 
murmur of mitral insufficiency. This is one of the murmurs that 
is not always constant ; on the contrary, it may come and go, and 
sometimes does not appear at all. Here the impediment in the 
flow of blood lies between the left auricle and the left ventricle. 
As a result the left auricle and the right ventricle may be hyper- 
trophied and dilated ; in some cases the left ventricle alone is 




Fig. 53. — Cirrhosis of the Liver. Passive Congestion from Mitral Stenosis. X 50. 

thus influenced, or in some few cases the whole heart, and espe- 
cially the left ventricle, is unusually small. 

Aortic insufficiency is for the most part of merely theoretical 
interest to us, as it hardly ever occurs in childhood. Its murmur 
comes with the second sound, is most plainly heard at the sternum, 
especially on the right side, between the second and third inter- 
space, and is transmitted upward to the right and also down the 
sternum. The lesion gains its activity in the diastole of the heart, 
and is the cause of regurgitation from the aorta to the left ventri- 
cle. Consequently with this lesion one may expect to find dilata- 



DISEASES OF THE HEART 313 

tion and hypertrophy of the left ventricle, or at times the ventricle 
is merely dilated. This condition more than the others is apt to 
give rise to cerebral symptoms. 

Aortic stenosis is also rarely heard in children. Its murmur 
is systolic, heard at mid-sternum opposite the third interspace, 
and is carried over into the silence between the two sounds. It 
is usually transmitted up the sternum to the right and sometimes 
down the sternum. Sometimes it may be heard at the back to the 
left of the third dorsal vertebra. Occasionally on autopsy one 
finds an aortic stenosis in a case that presented no murmur at all. 
As a result of the lesion both left and right ventricles are dilated 
and hypertrophied. One can easily understand how this comes 
about, because the flow of blood from the left ventricle into the 
aorta is impeded. Both aortic stenosis and insufficiency are apt to 
accompany mitral disease rather than occur alone, although they 
sometimes happen alone in congenital heart disorders. 

Tricuspid insufficiency is for the most part of theoretical inter- 
est. It originates in a rough ventricular surface, or may be due 
to the presence of thrombi in the ventricle. It is not constant, 
and when it can be plainly heard is fairly sure to accompany 
mitral disease. It is systolic, most plainly heard just to the right 
of the apex, and is circumscribed. Usually it is diagnosticated on 
autopsy. 

The other symptoms do not occur in any fixed order, and may 
for considerable periods be absent, at any rate in an acute form. 
The child is apt to be weak and poorly nourished ; but until com- 
pensation fails he is apt to cause no unusual wony. At the same 
time he is very liable to react unfavorably to exposure of any 
sort. Mental excitement is apt to affect him very unfavorably, 
and his frequently changing condition will perforce excite com- 
ment. He is subject to pain, which he refers to the heart, to 
malnutrition and anaemia, to headaches, dyspnoea, and, in the 
event of unusual strain, cyanosis. 

In young children one of the symptoms first noticed is the 
unusual heart and pulse actions. We do not so constantly look for 
differences of tension, which when they exist at all are so slight, 
and so hard to distinguish as to possess little diagnostic value. 
The action may be wild, irregular, intermittent, or weak. When 
it is weak, one is often able to count a greater number of pulsa- 
tions in the arteries than beats of the heart. The temperature is 



314 



THE MEDICAL DISEASES OF CHILDHOOD 



variable, depending upon associated conditions. The respiration 
often follows the pnlse, and when the disease is at all severe the 
dyspnoea may be alarming. When it is very bad, cyanosis will 
naturally follow. 

In some severe cases one may find a subacute nephritis in 
which the urine contains albumin and occasionally casts. A more 
frequent set of symptoms may be referred to the lungs, where the 
congestion may occasion a bronchitis. In other cases a true 
pneumonitis, also of a subacute type, may be distinguished. This 
pneumonia is of an obstinate character, for not only are the capil- 









■-;- 






Fig. 54. — Pneumonia of Endocarditis. X 50. 



laries dilated and the lung tissue in a state of hepatization, but 
also the walls of the air spaces are materially thickened, and there 
is a considerable laying down of new connective tissue. In such 
an inflammation the color of the lung shows the effect of a pig- 
mentation and is darker than in a primary inflammation. 

The symptoms of congenital endocarditis are mentioned on 
page 43. 

Treatment. — The treatment is largely symptomatic. Heart 
stimulants and tonics may at various times be needed. At others 
it may be necessary to treat complicating symptoms. It is always 



DISEASES OF THE HEART 315 

desirable to correct the anaemia which springs up on slight provo- 
cation and persists with obstinacy. Even small attacks of physi- 
cal deterioration require careful attention and tonics. When 
compensation is defective digitalis is beneficial, especially upon 
the left heart, while strophanthus has a good influence on the right 
side. In the flurry of an acute exacerbation, especially in the 
older children, the use of opium will often give valuable results. 
Strychnine or mix vomica is a very useful drug, and may be 
combined with iron or the simple bitters. Most of all it is of 
the highest importance to regulate every part of the child's daily 
life, every detail of rest, exercise, clothing, and study. Regular 
and systematic exercise should be prescribed, always excluding 
whatever involves much strain. Thus, walking, riding, driving- 
and similarly moderate exercises are of the greatest benefit. The 
child should be under constant supervision so that no detail may 
escape observation. 

Prognosis. — The outcome of the disease is better than one 
would expect. Compensation comes quickly in children. And 
even in severe cases the patient will sometimes live and seemingly 
recover in the face of disabilities which at first seemed inevitably 
fatal. Nevertheless a guarded opinion must be given, even in mild 
attacks ; this is especially true when the general circumstances of 
the patient are not of the best. 

Malignant or Mycotic Endocarditis 

This form of endocarditis in children has been regarded as a 
pathological curiosity. It doubtless occurs rarely ; and therefore 
when it does, it may be so difficult of detection that one should 
not be too much blamed for failing to recognize it. Most of our 
information concerning it comes from the study of adult cases, but 
as there is practically no difference brought about by age, and 
since the degree of fatality in children is as severe as in adults, 
such knowledge efficiently serves our purpose. 

Causes. — The disease does not occur as a primary disorder, 
but follows such sicknesses as are able to provide the infecting 
material. These are the acute infectious fevers, purulent diseases 
of the bones, septicaemia, and pyaemia. In these cases, no matter 
with what sickness they may be associated, cultures made from 
the vegetations show the presence of diplococcus lanceolatus. 



316 



THE MEDICAL DISEASES OF CHILDHOOD 



staphylococcus pyogenes aureus, gonococcus, or streptococcus 
pyogenes. A previous lesion of the endocardium favors the 
lodgment and development of the bacteria at the affected part. 
Lesions. — The pathological process seems to start from the sub- 
endothelial layer. The involved parts become swollen, filled with 
white cells, and covered with fibrin and bacteria. Here and there 
the endocardium is covered with vegetations of different sizes and 
of varying consistency. The smaller ones as a rule gradually 
accumulate a fibrinous covering which checks further development 




Fig. 55. — Aortic Valve: Acute Mycotic Endocarditis. X 30. 



and change. Or the process may not stop here ; the vegetations 
may increase in size to a marked extent, and alter their com- 
paratively benign character. They then seem to be made up of 
necrotic tissue, proliferated endothelium, and masses of bacteria. 
Coagulated blood is deposited on them and helps to swell their 
size. Such parts have a tendency to break down in necrosis, 
thereby forming ulcers ; detached portions are torn away by the 
blood current, and find a lodgment either in the heart cavities 
or any of the viscera. Thus they may act as thrombi or emboli 
of an infectious nature. 



DISEASES OF THE HEART 



317 



Symptoms. — The physical signs do not differ naturally from 
those of an acute simple endocarditis. The disease may be 
ushered in with a chill, or there may be a number of them ; never- 
theless this is not invariably the case. One naturally expects to 
see ordinary symptoms of endocarditis plus those of a septicemic 
invasion. The temperature may mount up to 41° C. (106° F.) 




PULSE, RESPIRATION AN*D TEMPERATURE CHART OF MALIGNANT ENDOCARDJTIS. 
AGE, 9 YEARS. 

pulse _ temperature_. — ._. respfratio-n 

Fig. 56. 



or more in the evening, and then in the morning may fall two 
or more degrees. It may be very irregular, or even distinctly 
remittent. The quality of the pulse and the character of the res- 
piration follow the variations of temperature, the pulse especially 
showing a disposition to become irregular. There may be symp- 
toms of embolism, more frequently referred to the cerebral arteries 
than to other vessels. The urine regularly contains albumin and 



318 THE MEDICAL DISEASES OF CHILDHOOD 

casts, the spleen usually is enlarged, soft, and tender, the liver 
may be enlarged, the serous membranes may become subject to 
acute inflammation either simple or purulent, and the joints may 
be similarly affected. In the more mature children lodgment of 
emboli may cause paralysis, in infants more frequently convulsions. 
Any or all of the valves may be involved, so that one is apt to 
hear various murmurs. Some authors believe that the rarer heart 
murmurs should always suggest malignant endocarditis. 

Treatment. — The treatment is purely symptomatic. One 
should do everything possible to keep up the patient's strength. 
Even although the prognosis is thoroughly bad, nevertheless one's 
efforts should never relax. It is especially important to use stim- 
ulants up to the point of toleration. 

Prognosis. — The outlook is gloomy. One cannot give a re- 
liable opinion which will cover all cases ; in fact, each must be 
worked out by itself, and the separate factors of endocarditis and 
septicemic infection must be regarded as complementary forces. 
Few children survive the disease. 

Differential Diagnosis. — The diagnosis is often very hard to 
make. The most one can say is that an endocarditis which has an 
emphatically septicemic character may be taken to be mycotic. 
The presence of a remittent temperature may cause the observer 
to make a diagnosis of malaria. But in this event there will be 
no characteristic history, no plasmodium in the blood, and no 
response to the administration of quinine. In addition, observa- 
tion of the disease will soon correct the error. Very commonly 
the diagnosis is made on autopsy. 

Cardiac Hypertrophy and Dilatation 

There is a large class of cases in infants and children to which 
sufficient attention has not been given. The patient complains 
of symptoms which are referable to the heart, and yet one can- 
not hear heart murmurs nor distinguish the regular signs of endo- 
carditis. Such cases are apt to worry the parents as well as the 
physician ; for, although the children do hot seem dangerously 
sick, nevertheless they have many disturbing symptoms, and their 
general development is substantially retarded. These cases come 
properly under the head of hypertrophy and dilatation, presenting 
the picture of an overacting heart. 



DISEASES OF THE HEART 319 

Cardiac hypertrophy is more frequent in infants and children 
than in adults, partly on account of the weaker muscular tissue, 
partly from the frequency of the responsible causes. In some 
instances it seems to occur as a congenital condition. The usual 
rule, however, involves the idea of a naturally weak and pliable 
tissue put to a severe test, and thus showing the effects of strain. 
The cases of muscular strain due to prolonged work and athletic 
exertions in adults are replaced in children with strain due to 
violent coughing (as in pertussis or severe bronchitis or asthma), 
or excessive crying ; to the constant restlessness, the running, 
jumping, and continuous activity of early years. As far as prece- 
dent pathological disabilities go, one should mention, as predis- 
posing causes, endocarditis, serious pulmonary disease, congenital 
atresia of the aorta, chronic nephritis, rheumatism, the acute 
infectious diseases, and prolonged disorders of malnutrition. 

Cardiac dilatation, like hypertrophy, may be seen much oftener 
in children than in adults. It may happen as a fortunate accom- 
paniment of hypertrophy, resulting in an equilibrium between 
these two abnormal conditions. In consequence, the heart may 
work in a regular and satisfactory way, and in the course of its 
normal development may use the increased size in place of the 
expected growth. Thus the child may in time lose all trace of 
his previous lesions. On the other hand, it may come less fortu- 
nately as an induced condition of heart weakness after cardiac 
and pulmonary disease, in which the blood pressure has been 
greater than the heart muscle's power of resistance. Again, a 
thinning of the muscular structure, due to wasting diseases, may 
cause larger cavities than are normally found, although the size of 
the whole heart is not increased. Another common cause, in 
young children even more than in youths or adults, is acute 
inflammation of the lungs and pleura. This action comes about 
by obstruction of the pulmonary arterioles so that the blood is 
dammed back upon the right heart. In such ways one can 
account for the origin of many cases ; on the other hand, one is 
apt to meet patients in whom no assignable cause can be discovered. 
In all likelihood the aetiology of these cases is obscure simply 
because of the habit of poor observation in regard to young children. 

Symptoms. — An hypertrophied heart may often be diagnosti- 
cated on inspection. The chest walls are so thin and pliable, that 
the increased size of the heart is seen by the bulged-out contour 



320 THE MEDICAL DISEASES OF CHILDHOOD 

of the prascordium. The apex beat is likewise seen with greater 
distinctness than in normal cases, while its position is changed 
according to the line of greatest increase. If the left ventricle 
alone is hypertrophied, the length of the heart is increased. Natu- 
rally the beat would then be seen farther to the left as well as 
lower down. If the right ventricle alone is hypertrophied, the 
heart increases in size on its right side This would not neces- 
sarily change the apex beat at all, or it might be seen farther to 
the right than normal. When both are hypertrophied, the result 
would naturally be the sum of both. 

Percussion will show an increased area of dulness, and when 
carefully practised will sometimes tell us what part of the heart is 
increased. 

Auscultation will give a muffled and softened first sound 
which is in contrast to the sharp, hard, and definite character of 
the second. 

In dilatation one looks for the greatest changes in the auricles 
sooner than in the ventricles. The apex beat may again be 
changed if the dilatation is accompanied by hypertrophy ; other- 
wise it is in its normal position. In the latter case one does not 
look for a bulged-out chest wall ; in fact, the conformation of the 
anterior thorax may not, unless in the presence of further patho- 
logical factors, be materially changed from the normal. By 
palpation one may notice the weak, weary, and undecided heart 
action. In other cases this weakness may be so marked that the 
impulse is very gently spread over a comparatively large surface ; 
as a result one can often detect it with the eye even though the 
superimposed hand is unable to feel it. 

From dilatation alone one commonly does not expect much of 
a change in the percussion note. On auscultation one hears a 
sharp, metallic accent to both sounds which gives the impression 
of strain or effort. On slight provocation such a heart loses its 
normal and regular action, taking on a functional character that 
may be eccentric and puzzling. 

One of the most noticeable symptoms of hypertrophy and 
dilatation is a short, hard cough, occurring without adequate 
involvement of the lungs. This cough is worst at night and 
early morning, while during the day it may almost be, and pos- 
sibly is, quite absent. In general the child's nutrition is apt to 
deteriorate, he looks pale, he lacks energy, his appetite is poor, 



DISEASES OF THE HEART 321 

and he is inclined to suffer from attacks of bronchitis, headache, 
and the effects of vicarious congestions. The mental condition 
may be somewhat similarly influenced so that it is noticeably dull 
and apathetic. 

Treatment. — Attention to the regulation of the child's life, to 
the enforcement of quiet in action and habit, to strict hygienic 
and dietary control, and the administration of tonics will do much 
to eliminate the evil effects of these conditions, and allow the 
impeded heart to resume its normal size, contour, and functions. 
For the cough, large doses of bromide of soda, with or without 
nux vomica as the case demands, will be found of use. In older 
children codeine may prove of marked service. These drugs 
should be soon changed to tonics, such as the compound syrup 
of hypophosphites or the organic preparation of iron with small 
doses of strychnine. In the use of these means one should under 
no circumstances neglect the main factor of regulation of every 
detail of daily life. 

Prognosis The outlook usually is excellent, so that with 

conscientious attention the patient should in a short time be com- 
pletely cured. 

Anemic Murmurs 

Anaemic murmurs should in most cases be diagnosticated with- 
out much difficulty from those of organic heart lesions. They 
are not constant, there are no regular signs of heart disease, and 
there is no history of the antecedent conditions of endocarditis. 
As the functions of the heart are not altered, so its size and con- 
tour are not regularly changed. The child is plainly anaemic, 
may for a time have systolic murmur, which is heard over the 
heart and the large vessels as well, and recovers in a compara- 
tively short time after appropriate treatment has been instituted. 
His improvement need not go very far before the murmur disap- 
pears. The treatment is that of the anaemia. 

Pericarditis 

The rare phenomenon of an inflammation of the pericardium 
is one of the most serious diseases from which infants suffer; 
older children stand the strain somewhat better, but even their 
greater vitality is poor when opposed to the wearing, exhausting, 



HH1MMH 



322 THE MEDICAL DISEASES OF CHILDHOOD 

and distorting effects of the disease. Generally we recognize 
three forms of inflammation, — one characterized by the produc- 
tion of fibrin, another by that of fibrin and serum, and the third 
by that of fibrin, serum, and pus. 

Causes. — The disease very rarely occurs as a primary dis- 
order ; often it accompanies or follows some sickness which has 
the power of general infection. In older children, as in adults, 
rheumatism is a common cause ; but infants, being less frequently 
rheumatic, do not so frequently exemplify this rule. Pericarditis, 



\ 




Fig. 57. — Normal Pericardium. X 50. 

in some very few cases, begins before birth as a so-called idiopathic 
affection, or as the result of septicemic contagion from puerperal 
disease in the mother, or from inherited vice. Under these con- 
ditions the effusion may be either serous or purulent. After 
birth it may appear, seemingly without cause, as the concomitant 
of nephritis, of inflammation of neighboring organs, as the lung 
or pleura, with endocarditis, with septicemic diseases either local 
or general, with bone diseases, and with the acute infectious 
fevers, notably scarlet fever and diphtheria. The micro-organ- 
isms commonly found in this disease are the usual streptococci 



DISEASES OF THE HEART 323 

and staphylococci of pus processes, the bacillus tuberculosis and 
bacillus lanceolatus. 

Lesions. — The pericardial membrane becomes congested, the 
capillaries being dilated and visible. Fibrin in varying amounts 
is thrown out and covers the surface irregularly. If the amount 
is large, adhesions are formed at the points of greatest collection 
between the two pericardial surfaces. On recovery part of the 
exudate is absorbed ; the rest, however, may remain and slowly 
give way to permanent connective tissue. A large number of 




Fig. 58. — Simple or Fibrinous Pericarditis. X 50. 

cases may in addition have an exudation of serum, more or less 
tinged with blood. It collects in the lower and posterior part 
of the sac, forming a wedge-shaped body. The serum may be 
quickly or slowly absorbed, and then the fibrin remains as in dry 
pericarditis. This is what commonly happens in young children 
who may on post-mortem examination be found to have had a 
primary inflammation without fluid. 

The purulent form is likewise more common, comparatively, 
in children than in adults. Here there is a distinctly purulent 
exudation tinged with blood. Also one notices a fairly large infil- 
tration of the membrane itself, with small cells. This class is natu- 



324 



THE MEDICAL DISEASES OF CHILDHOOD 



rally the most serious, because the exudate is both large in quantity 
and poisonous in character. Likewise does this class leave the 
largest number of permanent changes, such as adhesions between 
the pericardial surfaces, a tendency to septicemic attacks, the 
formation of connective tissues which become thickened and 
toughened by calcific infiltration, a proneness to tuberculosis, 
usually pulmonary. 

At times one sees a form of pericarditis that may roughly be 
called hemorrhagic. The dilated and newly formed vessels, as 




Fig. 59. — Acute Sero-Fibrinous Pericarditis, x 30. 



well as the surrounding tissue, are very delicate, and at the least 
provocation break, allowing hemorrhage in various degrees. 
And even without a direct rupture there may be an effusion of 
blood through the wall of the vessels. This form is always 
serious, more on account of the physical depression which accom- 
panies this condition than the mere fact of the haemorrhage. 

Symptoms. — In the first form there may be a friction sound, 
which when present is characteristic. It can be heard at both 
first and second beats of the heart, but not exactly synchronous 
with them, and is independent of the breathing. It is apt to dis- 



DISEASES OF THE HEART 



325 



appear quickly, especially if effusion is present, but on absorption 
may reappear. When present, it is best heard at about the nipple 
line, between the nipple and the sternum. It is usually harsh 
and rubbing, and when once heard should not be confused, as it 
sometimes is. with a congenital heart murmur. 

With effusion of serum the area of dulness is increased, and 
assumes a roughly triangular shape having its base at the bottom. 
Formerly it was thought that this general form was easily con- 
fused with that of an enlarged heart, but that the latter was 




Fig. 60. — Acute Fibriuo-Puruleut Pericarditis, x 30. 

differentiated by a space of dulness to the right of the sternum. 
Since then observations and experiments, notably those of Rotch, 
have demonstrated that a pericardial effusion commonly gives an 
even greater area of dulness to the right of the parasternal line 
than the enlarged heart. The main point of distinction lies in 
the general form of the area of dulness : that of the enlarged 
heart resembles a truncated ovoid, while that of effusion is, as 
stated above, a triangle which rests like a saddle upon the dia- 
phragm. As the fluid incr eases in quantity, the pericardium is 
apt to thicken, the heart sounds are muffled, and the pericardium, 



mm 



326 THE MEDICAL DISEASES OF CHILDHOOD 

on account of the pliability of the chest walls, is apt to bulge out. 
In very marked cases the dulness may cause an alarming dyspnoea 
with cyanosis. 

In the purulent form there is a tendency to a large exudation 
and a chronic course. The apex beat, owing to the effusion, may 
be absent, but in its place one often feels a wavelike impulse 
which may be transmitted to some distance from its source. In 
the newly born the only sign may be a wild heart beat ; the older 
children have a greater liability to begin the disease with a chill 
or convulsions. The physical signs may be somewhat obscured or 
changed by adhesions, but these occur much less often in children 
than in older patients. This new tissue finds its natural and best 
opportunities for growth in the purulent exudation, and the 
additional gravity which it entails is always considerable. 

Precordial tenderness, especially in older children, is always 
apparent. The patient is easiest when lying with rigid body and 
elevated head, and change of position induces discomfort and 
oppression, which increase in proportion to the amount of displace- 
ment and compression of viscera. In the third or purulent form 
there are, in addition, the symptoms of septicemic invasion, the 
lowered vitality, the worried, anxious look, the tendency to stupor 
and convulsions. The disease may be complicated with a myocar- 
ditis either circumscribed or diffuse, an endocarditis which is 
usually very dangerous, or an extension of the disease to some 
other serous membrane. 

There may be an effusion of serum into the sac caused by heart, 
lung, or kidney disease, by malformations or tumors of the chest. 
Since there is no inflammation involved, the condition is called 
hydro-pericardium. A related phenomenon, hsemo-pericardium, 
consists of the presence in the sac of a fairly large quantity of 
blood which has escaped by rupture of the arterioles. Or by fer- 
mentation of putrefactive material there may be a production of 
gas. This is the so-called pneumo-pericardium. 

Treatment. — The two main indications for treatment are the 
tendency to heart failure and the presence of pain. The first is 
combated by digitalis, strychnine, and tonics. Entire ease and 
undisturbed rest must be provided. For the pain bromide of 
soda in infants and opium in older children may be necessary. 
Some relief can almost always be obtained by the use of cold 
applications, such as light ice-bags. The diet must be as light 



DISEASES OF THE HEART 327 

and nutritious as possible, and every attempt to help excretion, 
especially by the kidneys, must be made. When the effusion 
collects much more rapidly than it can be eliminated, it may be 
necessary to practise paracentesis. This is accomplished by aspira- 
tion of the pericardial cavity in the fifth right or left intercostal 
space. In some few cases of purulent effusion, it may be neces- 
sary to resort to the dangerous operation of opening and draining 
the pericardium. Naturally, when there is an antecedent disease, 
its treatment must occupy a place of much importance. 

Prognosis. — The outlook is generally unfavorable, and espe- 
cially so when there are complications. 

Differential Diagnosis. — The condition with which pericarditis 
may be confused is endocarditis. Between these two diseases the 
principal point of differentiation is the abnormal sound which is 
heard on auscultation. In pericarditis it is crisp and harsh, it 
accompanies both sounds of the heart, it may under certain cir- 
cumstances disappear and reappear, and it commonly fades away 
as the disease subsides. This, as one can immediately see, consti- 
tutes quite a different impression from what one finds in endo- 
carditis. If effusion is present, the added signs will make the 
diagnosis yet clearer. 



Chroxic Pericarditis 

Lesions. — In the chronic form the lesions are the same as in 
the acute, with an accentuation of the tendency to form connec- 
tive tissue and curiously shaped adhesions. 

Symptoms. — The symptoms after the acute attack may be not 
especially prominent. The physical signs are much the same as 
in acute pericarditis, with the possible addition of distortions of 
the chest, an enlarged heart, myocarditis, and endocarditis. There 
may be recurring attacks of cardiac weakness, and a general mal- 
nutrition. Exact diagnostication of the condition calls for judg- 
ment and thoroughness of examination. 

Treatment. — The treatment tries to build up the general 
health and strength by every aid which tonics, diet, and hygiene 
can afford. Each case will call for its own proper methods, for 
what may be needed for one child would for another be super- 
fluous. The varying needs of the patient will, in all likelihood, 



328 THE MEDICAL DISEASES OF CHILDHOOD 

call for the exercise of the full resources of the attending phy- 
sician. 

Prognosis. — The outlook is not good. The patient has a 
probable future of weakness, functional debility, recurring exacer- 
bations, and complicating visceral congestions. His parents or 
attendants should regard him as living under a constant threat. 



CHAPTER XYII 

DISEASES OF THE BLOOD 

Simple Secondary Anemia 

As the result of unfavorable and exhausting conditions, chil- 
dren easily fall into a state of hsemic deterioration. The younger 
the child, the more easily does this happen, and the more serious 
are the results apt to be. On the other hand, they recover with 
comparative ease, so that such an anaemia bears the characteristics 
of a transitory phenomenon rather than a definite disease. Logi- 
cally, it is a symptom whose appearance can be predicted, provid- 
ing certain precedent causes, organic or functional, have been set 
in motion. These causes are descent from parents who, at the 
time of conception and pregnancy, are anaemic and exhausted, de- 
ficient blood supply or haemorrhage from the cord, hereditary 
disease, and poor quality of food during the first few weeks of 
life. After this initial period every factor which makes for defi- 
cient nutrition, for impaired function, for waste of tissue, and for 
organic disease, may likewise be regarded, indirectly at least, as a 
cause of anaemia. This is so constant and significant a factor in 
the care and development of a child, that it must be reckoned 
with in every abnormal condition in which he may happen to be. 
In infants the most fertile causes of ameniia are provided by the 
various severe disorders of the stomach and intestines, which not 
only absorb vitality, but also diminish the possibility of assimila- 
tion and growth. As the, child grows older, the number of dis- 
eases which affect him become larger ; and, likewise, there is a 
correspondingly larger amount of toxines and tox-albumins ab- 
sorbed, which are in large part responsible for the process of 
degeneration in the quality of the blood. Under this heading 
come such diseases as tuberculosis, diphtheria, scarlet fever, and 
the other infectious diseases. Closely allied to these, as -far as 
their effect goes, are unhealthy environment, uncleanliness, bad 
food, intestinal parasites, and pathological conditions like rickets 

329 



HI 



330 THE MEDICAL DISEASES OF CHILDHOOD 

and scurvy. In fact, in practically all diseases it is very likely 
true that anaemia results not so much from what is taken from 
the system as what is added, in the form of poisonous products, 
to it. Even in malaria, in which we know that the plasmodium 
attacks the red blood corpuscles themselves, it is not at all cer- 
tain that the anaemia is due entirely or mostly to this struggle, 
but rather to the formation of toxines which are simultaneously 
formed. The action of certain well-known drugs, such as most 
salts of mercury, the iodides, and potash salts in large doses, is 
often fully as sure as that of rheumatism or nephritis. 

The changes are confined, for the most part, to the blood. 
There is a variable decrease in the number of red blood cor- 
puscles, of haemoglobin, and the specific gravity. In addition, 
many of these cells may be altered or injured in form and possibly 
in function. The leucocytes are often increased both relatively 
and actually. 

Symptoms. — The most prominent sign of the sickness is the 
paleness of the skin, mucous membranes, and ocular sclerotic. 
The ears and the tips of the fingers and toes have a particularly 
blanched appearance. The child is listless and weak, irritable, 
not easily interested. The appetite is poor and fickle, and diges- 
tive disturbances of the gastro-intestinal track are common. The 
cardiac action is weak and sometimes irregular. Anaemic mur- 
murs may be heard over the precordial region, and a loud buzzing 
sound may often be distinguished over the great veins of the 
neck. Children who are able to run about may complain of 
dyspnoea or a short, dry cough that is at its worst at night and 
morning. The weakened circulation renders congestive disturb- 
ances of the lungs probable ; and with this is associated a prone- 
ness to inflammations of the nose and throat. At such times the 
hypertrophy of the pharyngeal, as well as the faucial, tonsils is 
easily contracted, and may give so distinctive a mark to the 
symptoms as to stand out as the primary cause of the general 
condition, while the anaemia may be taken as one of the results. 
Haemorrhage from the nose and throat is not infrequent, but is 
rarely serious. The spleen and lymphatic nodes may be enlarged, 
although not always enough to be plainly perceptible. On the 
other -hand, the glands of the mediastinum may be sufficiently 
hypertrophied to give pressure symptoms. 

These poorly nourished children are liable to subjective 



DISEASES OF THE BLOOD 331 

impressions that may have a far-reaching effect. During sleep 
they may have alarming dreams that make serious impressions on 
the mind, and turn it toward abnormal manifestations. Such 
impressions may persist in their waking hours, and may color the 
whole child life with a false hue. They may have pains in the 
head, over the heart, in the abdomen and extremities, that are apt 
to mislead one into conjecturing some local disease of the part 
affected. Some children become troubled with a weakness of 
sphincter control, which is oftener seen in the bladder than the 
rectum. Anaemic girls of any age often have some leucorrhceal 
discharge that cannot be entirely cured until the anaemia has 
disappeared. 

The treatment consists in removing, as far as possible, the 
causes, and following the directions concerning hygiene and drugs 
which are recommended near the close of the section on primary 
anaemias. 

The outlook is good in almost all cases. Where doubt should 
be felt is in those somewhat unusual instances of prolonged neglect 
which appear in hospital and dispensary practice. This does not 
include the extreme anaemias which occur in the course of long 
drawn out diseases. In these children it is hard to apportion to 
each phase of the sickness its suitable responsibility. 

In ordinary attacks there is little chance for confusion. It is 
only in the very severe cases where one may be in doubt whether 
the complaint is not chlorosis or pernicious anaemia. In simple 
secondary anaemia there is a simultaneous reduction in both 
haemoglobin and red blood-cells, in chlorosis the greater reduc- 
tion is in the haemoglobin, while in pernicious anaemia the 
decrease is the most marked in the red blood-cells. 

Chlorosis 

This disease in past times was called morbus virgineus, since 
it occurs mostly among young girls. From ten or twelve up to 
seventeen or eighteen years is the usual time for the disease to 
appear. It is not, however, confined to this period of life, but 
may occur in young and even middle-aged women. Although it 
is largely a disease of girls, nevertheless one occasionally sees 
instances of it in growing boys which correspond to all the 
ordinary tests. This item has for a long time been one of the 



332 THE MEDICAL DISEASES OF CHILDHOOD 

grounds of contentions which have nourished so richly in 
the various phases of this disease, — one party contending that 
chlorosis is exclusively a complaint of young girls, the other that 
it appears in both sexes. But there is so much uncertainty in 
our ideas covering all the parts of chlorosis that no special stress 
need be laid on this point. 

Causes. — The origin of this disease is unknown. Many theo- 
ries have been enunciated to account for it, but one after the other 
has been overthrown with greater ease than is required in most 
doubtful diseases. Poor food and unhygienic surroundings have 
been cited as causes; but they are plainly not responsible, for 
many of these patients are in these respects fortunately situated, 
while as a counter fact every one knows that only a small percent- 
age of the vast number of young people in poor circumstances 
have chlorosis. The disease occurs alike among the rich and 
poor, in the city and the country. Emotional excitement is just 
as unreliable as a sufficient cause ; and the same may be said of 
losses of blood by haemorrhage. Heredity seems to exert some 
influence, especially in those families where a large number of 
children is the rule. Even this influence is partial and does not 
explain the large number of cases in which there is no history of 
parental chlorosis. Some writers have laid much stress upon 
auto-intoxication from the intestinal canal, others upon uric acid 
poisoning, and still others upon an unknown microbic agent as 
the effective aetiology . But one and all are not proven. It is 
scarcely necessary to refer to the theory of hypotrophy of the 
arterial system, although it has been a favorite theory in Ger- 
many. In short, we are as far from a solution of the problem 
as we can be, especially in view of the centuries of familiarity 
with the clinical aspects of the disease. 

Lesions. — Changes occur in the blood and viscera ; and the 
more thoroughly one examines these cases, the more widespread 
are the effects of the disease found to be. The blood is thinned, 
is brighter in color than normal, tending to assume an orange hue. 
Its haemoglobin is much diminished in amount, being two-thirds 
or even one-half as much as normal. The red blood-cells are less 
reduced in number, and irregular forms may be seen ; the number 
of poikilocytes, microcytes, and megalocytes varies from case to 
case. The number of blood-plaques is greater than normal, but 
that of leucocytes is practically unchanged. The specific gravity 



DISEASES OF THE BLOOD 333 

of the blood as a whole is somewhat lowered, while that of the 
serum is unchanged or raised. The reaction of both serum and 
the whole blood is in many cases more strongly alkaline than 
usual. Although the amount of fibrinogen is decreased, the 
tendency to the formation of thrombi is increased. 

The heart and the great vessels have been found in some sub- 
jects to be under-developed. At the same time the cardiac fibres 
may be sufficiently weakened to produce a dilated right side with 
a compensatory hypertrophy of the left ventricle. There is a 
tendency all through the viscera to fatty degeneration, which is 
not easily distinguished excepting in severe and prolonged cases. 
In the heart it seems to make most headway in the left ventricle, 
and may extend to the vessels. It may gradually involve parts of 
the liver, the spleen, the stomach, and possibly the intestines. In 
the stomach the circulation may be sufficiently imperfect to allow 
the breaking down of small areas of mucous membrane. Most 
frequently the lack of tone in the gastric muscular tissue is great 
enough to render temporary dilatation from the piled-up food or 
the gas of fermentation inevitable. In some cases a lack of devel- 
opment in the uterus and appendages has been observed. 

Symptoms. — One of the most characteristic signs is the pecul- 
iar yellow or yellow-greenish pallor of the skin. Most of these 
patients have a waxy uniformity of complexion ; but there are 
exceptions in whom there is a bright patch on the cheek-bones. 
The mucous membranes are blanched, the sclerotic has a bluish 
tinge, the ear is waxy. The pupil is commonly dilated, and helps 
to give vivacity to the rather expressionless face. For the mus- 
cles may become so atonic as to be partially inefficient in depicting 
fine changes of emotion. The pulse is apt to be irregular and 
weak, the area of cardiac dulness is increased to the right ; and 
on the least exertion the patient complains of dyspnoea. Hsemic 
murmurs may be heard over the region of the pulmonary artery, 
the aorta, or the apex, which are doubtless due to muscular flaccicl- 
ity. These are often increased when the girl lies down, and 
under all circumstances are apt to vary in intensity. In the 
large veins of the neck a humming, buzzing sound may be heard, 
which is often greater on the right than on the left side. This 
likewise is variable, and from time to time may change considera- 
bly. There may be oedema of the feet and under the eyes which 
has no relation to a nephritis. 



HM 



334 THE MEDICAL DISEASES OF CHILDHOOD 

In the digestive system almost all of the changes are based on 
atony. There may be constipation, fermentation of gastric and 
intestinal contents, and a temporary dilatation of stomach and 
often of the colon. The tongue is pale, fairly clean, and thick. 
The appetite is poor and capricious, sometimes perverted. Sud- 
den nervous impulses may turn it in one direction or another. 
Not only in this respect but in the various functions and capabili- 
ties of the whole body these diverse influences play an important 
role. They may give rise to headaches, nausea, divers neuralgias, 
choreic symptoms, unreliable caprices, and outbreaks of multiform 
hysteria. There may be amenorrhcea, dysmenorrhoea, or menorrha- 
gia. Rarely, in older girls, a thrombosis of the cerebral sinuses 
or of the veins of the legs has occurred. Many observers have 
remarked a " chlorotic fever," which seems to me to be caused by 
some intercurrent condition rather than by the chlorosis itself. 

The treatment is given near the end of the section on anaemias. 

Prognosis. — The outcome of this disease, although it may be 
delayed by various fluctuations, is almost always favorable. One 
of the greatest obstacles resides in the fickleness and unreliability 
of the patients, which render strict obedience to orders difficult. 
Thus the course of the disease may extend over months or even 
years. But so long as the condition has been accurately diagnos- 
ticated and the treatment faithfully carried out, a cure should 
result within a time measured by weeks rather than months. 

Differential Diagnosis. — First of all one should ascertain 
whether the anaemia is primary or dependent on some precedent 
complaint, such as malaria, rheumatism, lead poisoning, nephritis, 
and other exhausting diseases. If these factors have been ex- 
cluded, an examination of the blood, combined with the objective 
signs of the disease, Avill clear up any doubt. 

Pernicious Anaemia 

Chlorosis is mysterious in its origin ; and if one may make a 
comparison, pernicious anaemia is much more so — it is baffling. 
While no one pretends to know how it arises, very many writers 
follow the classic examples of suggesting as possible causes all of 
the ordinary difficult and exhausting conditions in life. Thus, 
over-work, over-worry, intestinal parasites, severe sicknesses, pro- 
found anaemia, exhausting haemorrhages, congenital syphilis, rachi- 



DISEASES OF THE BLOOD 335 

tis, auto-intoxication from the intestines, severe diseases of the 
gastric and intestinal mucous membranes, and micro-organisms 
have been mentioned. The connection between any or all of these 
diseases and pernicious anaemia has not been proven ; on the other 
hand, it partakes largely of the nature of coincidence. As a coun- 
teract one may note the occurrence of all these conditions without 
the sequence of pernicious anaemia, and the appearance of the 
anaemia without any visitation of the preliminary disorders. The 
true cause is yet to be discovered. 

Lesions. — The blood is paler than normal, and its specific 
gravity is low. The striking feature is the great reduction in 
the number of the red blood-cells, which at the worst stages of 
the disease may be only 500,000 or even less to the cubic milli- 
metre. Not only are the cells decreased in number, but also they 
are altered in form. The large proportion of poikilocytes is very 
striking, and some of them have been said to exhibit active move- 
ments. In addition there are fairly large amounts of microcytes 
and macrocytes. Nucleated corpuscles occur in their various 
phases of gigantoblasts, normoblasts, poikiloblasts, and micro- 
blasts. The nuclei as well as the blood-cells vary in different 
cases in their disposition to take up stains. The number of leu- 
cocytes may be slightly decreased and the cells themselves may 
be small in size. The blood-plaques are reduced in number. 

Haemoglobin is reduced in quantity, but not as much as the 
red blood-cells. It may be found in the plasma, as may met- 
hasmoglobin, and in some red blood corpuscles is present in 
unusually large amounts. The reaction of the whole blood is 
often markedly alkaline, on account of the increase in the alkaline 
chlorides, while at the same time the phosphates are diminished. 
The total quantity of blood seems to be diminished. 

Throughout the thoracic and abdominal viscera there seems 
to be a noteworthy tendency toward the production of fatty 
degeneration ; even the diaphragm may be involved. The heart 
may show this change in any part of its substance, and as the 
degeneration occurs there will also be a simultaneous growth of 
dilatations in the weakened tissue. The liver, kidneys, spleen, 
and pancreas show areas of fatty degeneration and softening, 
as well as deposits of iron and pigment. The size of these organs 
may be increased, and they may be studded with patches of 
parenchymatous degeneration. The stomach shows some atrophy 



Mi^HM 



336 



THE MEDICAL DISEASES OF CHILDHOOD 



of its epithelium, its muscular layer is thin and easily dilated; 
similar lesions are present in the small intestines, and the mucous 
layer holds a noticeable excess of iron. The urine is markedly 
alkaline in reaction, contains some albumin and casts, especially 
hyaline, large amounts of normal and pathological urobilin, urea, 
and uric acid. After the disease has been actively set in motion, 
a sclerotic process may begin in the posterior cord which gradu- 
ally works its way around to the lateral and anterior columns, 
principally in the cervical portion. All through the body there 
may be small ecchymotic haemorrhages, in the cord, the mucous 




Fig. 61. — Liver in Pernicious Anaemia. X 25. 



membranes, the eyes, ears, and parenchymatous and subcutaneous 
tissues. Even the bone marrow may be degenerated and studded 
with minute haemorrhages and deposits of iron. 

Symptoms. — The symptoms begin mildly but develop and 
expand with inevitable sureness. The child at first is listless 
and without energy ; he loses appetite, and his complexion 
becomes pale and then dull, sickly yellow. Functional disorders 
of the gastro-intestinal track are common, and may assume many 
forms. Dyspnoea is regularly present and is increased on slight 
exertion. The heart action is weak, the pulse is soft and com- 



DISEASES OF THE BLOOD 337 

pressible. The apex beat is apt to be low and displaced to the 
left. Haemic murmurs may be heard at the aortic area and at 
the apex, but these may be in part caused by deficient coaptation 
of the valves due to cardiac dilatation. Over the great vessels in 
the neck one may hear a venous hum. In most cases there is a 
moderate, irregular fever, which may be due to the disease or to 
its complications. There may be some dropsy under the eyes, 
and later about the feet and ankles ; more rarely there may be 
effusion into the serous cavities. Haemorrhages, usually small in 
amount, may start from any of the mucous membranes, of which 
the nasal are the most fertile. Nervous symptoms mark the last 
stages and may be of varying severity. In some cases they are 
no worse than headaches, temporary lack of coordination, restless- 
ness, and insomnia ; in others they may go as far as the effects 
caused by haemorrhage into the brain or cord. 

Prognosis. — The outlook is bad ; there may be temporary 
improvements, and the fatal outcome may be delayed for months 
or even years. But the disease, so far as we know, is not curable. 

Differential Diagnosis. — We make sure of the diagnosis of 
pernicious anaemia by the slow, steady, and progressive course ; 
the evidence of haemorrhages and fatty degeneration. The prin- 
cipal guide is the examination of the blood, the changes in which 
have been described among the lesions. 

The treatment is given near the end of the section on anae- 
mias. 

Infantile Pseudo-leuc^mic Anemia 

A condition of marked leucocytosis with oligocythaemia has 
been described by Yon Jaksch which as yet has not secured full 
recognition as a distinct disease. Instances of it have not as yet 
been so common, and studies of it have not been so thorough that 
an exact and distinct picture is commonly recognized. Some 
observers have claimed that it is merely a profound anaemia with 
a very large percentage of leucocytes. On the other hand, Yon 
Jaksch, Luzet, Hayem, Monti, and Berggriin believe that it is an 
independent disease. Its cause is unknown, but it has followed 
severe anaemias and the exhausted conditions of rickets and 
syphilis. Practically all cases reported were under five years 
of aee. 



■H^H^ 



338 THE MEDICAL DISEASES OF CHILDHOOD 

The red blood-cells may be very much reduced in number, so 
that only one-half or less of the normal amount is present. Thece 
may be variously altered in form, and in different cases there may 
be varying proportions of poikilocytes, microcytes, macrocytes, 
and polychromatophilic cells. The leucocytes are very much 
increased in number, so that in marked cases they form from eight 
to ten per cent of the whole number of cells. These leucocytes 
may be seen in their different varieties. Lowit reports a case in 
which he discerned amoeboid bodies in the blood and spleen, the 
larger number being found in the latter. The spleen is much 
enlarged, but the lesions seem to be no more than a simple hyper- 
plasia which may include all parts of the viscus. The liver may 
be unchanged or slightly increased in size, and the hepatic cells 
are usually normal. The statement has been made that in this 
condition the liver has "reverted to the embryonic state." And 
this is still another instance of the lack of agreement in the mat- 
ter. The glands may be enlarged by a simple hyperplasia, but 
they are neither very great in size nor tender. 

The symptoms are those of an anaemic condition of much 
severity plus an enlarged spleen. The course is chronic and may 
be marked off by the variations in the size of the spleen. There 
may be exacerbations and remissions ; and there is a noticeable 
weakness in resisting intercurrent diseases. 

Prognosis. — The outlook in this complaint is supposed to be 
fairly good. But the extreme youth of the patients, as well as 
their necessarily exhausted condition, makes any serious impover- 
ishment of the blood a matter of danger. A mortality of twenty 
per cent has been reported. 

Differential Diagnosis. — The diagnosis is made from the 
greatly enlarged spleen and the equally great leucocytosis. 

Leucocyth^emia 

Leucocythsemia, or leucaemia, is a disease that one occasionally 
sees in childhood. At the time of the first report of this disease, 
in 1845, the general conception of it was simpler than ours at 
present is. Greater experience with it has shown the existence 
of two varieties : the one, which is called the spleno-medullary 
type, consists in the most part in an enlargement of the spleen 
and the presence in the blood of certain large mononucleated cells. 



DISEASES OF THE BLOOD 339 

The other variety, called the lymphatic form, is characterized 
by an excessive quantity of small mononucleated cells, while the 
enlargement of the spleen is not so marked as in the first case. 
This classification is not a final one ; and increased knowledge, 
as in most degenerative conditions of the blood, may overthrow 
the present beliefs. 

Causes. — We are ignorant of what causes leucocythaemia. 
Although the greatest proportion of the cases occurs among 
adults, nevertheless it does appear in children of the youngest 
age. In these instances it may be associated with or preceded by 
exhausting diseases, malaria, rickets, syphilis, profound anaemia, 
and unfavorable conditions of life. Attempts have been made to 
trace an hereditary connection, but they are not promisingly suc- 
cessful. 

Lesions. — The main change consists in the large number of 
leucocytes in the blood. This may be so great that the color of 
the fluid is noticeably light. If there is a coexistence of anaemia, 
the blood is thin and watery, and its hue has a yellowish cast. 
Although the amount of its fibrinogen is somewhat increased, it 
coagulates outside of the body with some slowness. The lym- 
phatic variety is somewhat commoner in children than in adults. 
It shows an increased number of mononuclear leucocytes. Of 
these, the larger forms contain considerable amounts of proto- 
plasm and some basophile granules, but the smaller ones have 
only a small quantity of protoplasm. As a rule, both of these 
forms are non-amoeboid. On the other hand, the polynuclear 
leucocytes and eosinophiles remain stationary in number. If 
there is a marked anaemia, one may notice a few nucleated red 
corpuscles. In the spleno-medullary form the leucocytes in gen- 
eral are increased in size ; most are finely granular, while only a 
few may be called coarsely granular, e.g. the mast-zellen of Ehr- 
lich. The principal varieties are the large mononuclear corpuscles 
or myelocytes, the eosinophile corpuscles, the polynuclear corpus- 
cles or cells with multipartite nuclei, and the coarsely granular 
leucocytes. In addition there may be many nucleated red blood 
corpuscles. In and about the leucocytes, Lowit reports the find- 
ing of sporozoa, and suggests from observation that these parasites 
go through a process of multiplication within the cells. He does 
not believe in the entire separation of the two varieties men- 
tioned above, and speaks of transitional forms between them. 



M^^ 



340 THE MEDICAL DISEASES OF CHILDHOOD 

The red blood-cells are diminished in numbers ; they may be 
so much decreased and the leucocytes so much increased that the 
two become equal to each other. The haemoglobin may be reduced 
in quantity in about the same proportion as the red blood-cells. 

In the viscera the changes are not confined to the spleen, as 
formerly so often thought, but may extend all through the body. 
Thus, there may be a leucocytic infiltration, a leucocytic throm- 
bosis, and haemorrhages. The spleen is much enlarged and is 
infiltrated with leucocytes like those found in the blood. It may 
contain infarctions or be subject to hyperplasia. In chronic cases 
there may be a fibrosis which involves the pulpy network and the 
trabeculae. The liver may be somewhat increased in size, but not 
so much so as the spleen. It is slightly pale in color, which may 
be due to anaemia, or leucocytic infiltration. This infiltration is 
most apt to occur about the portal track, from which it may work 
its way into the lobules. There may be some fibrosis followed by 
atrophy of hepatic cells. Where there is much anaemia there may 
be a fatty degeneration. The lymphatic glands, in the lymphatic 
form, are enlarged in practically all cases; in the spleno-medullary 
form they are rarely enlarged, and whatever enlargement exists 
is not at all great. In each variety the leucocytes are the same 
as those which are found in the blood. Bone marrow becomes 
altered by cell change and degeneration. It may be soft and 
have a resemblance to the appearance of a light-colored pus, or, if 
it is fluid and of a deeper pink hue, it may suggest lymphoid tis- 
sue. It replaces the fatty marrow in the shafts of the long bones, 
and may even bring about some absorption of particles of osseous 
tissue. The hyperplastic process is as consistent as in other parts 
of the body. The same general change takes place in the thymus 
gland, in the heart, where it is associated with fatty degeneration, 
in the lungs, where it brings with it thickening of the connective 
tissue, in the kidneys, in which the leucocytic infiltrations into 
the connective tissue may be noticeably large. In the alimentary 
canal similar hyperplastic processes in the glands of the mouth, 
stomach, and especially the intestines, may be expected, most of 
all in the lymphatic form. In the various viscera haemorrhages 
may take place, as well as on serous membranes, periosteal mem- 
branes, skin, and mucous surfaces. These seem to rise from a 
leucaemic infiltration of the walls of the arteries, followed by local 
degeneration and rupture. In this way haemorrhage may take 



DISEASES OF THE BLOOD 341 

place in the retina and inner ear. The amounts of excreted 
urea, uric acids, and xanthin bases in general has been found to 
be increased, but not regularly so. The phosphorus excretion is 
also said to be enlarged. 

Symptoms. — The appearance of leucocythaemia is alike in 
children and adults. The beginning is slow and barely percep- 
tible. The patient shows lassitude, weakness, anorexia, dyspnoea, 
disorders of the gastro-intestinal track, and often some pain in 
the left hypochondriac region. Examination shows an enlarged 
spleen, which may become so large that it approaches the superior 






^. 









Fig. 62. — Kidney : in Leucoeythaemia. x 100. 

margin of the ileum. Haemorrhages from the stomach, intes- 
tines, nose, throat, eye, or other regions may occur. There may 
be an irregular fever which does not rise to a great height. 
There may be an irregular adenitis which occasionally is painful. 
Anaemia is often noteworthy, and gives its regular symptoms, 
including weakness, headaches, soft pulse, haemic murmur at the 
apex, and changes in the composition of the blood. The com- 
plexion is dull, and especially at nights there may be some sweat- 
ing of the head and chest. There is an acute form in which the 
progress of the disease is very rapid, so that days or weeks instead 



342 THE MEDICAL DISEASES OF CHILDHOOD 

of months mark the limits of the disease. From the very begin- 
ning the symptoms are startling, the prostration is profound, the 
haemorrhages may be frequent and copious, and oedema of the 
lungs or an intra-cranial haemorrhage may suddenly end the child's 
life. From the very outset of the sickness the symptoms rage 
with so much intensity that very little hope can logically be 
entertained. 

Prognosis. — The outlook is, on the whole, bad. There may 
be periods of improvement, and death may be delayed for some 
months or even years. The lymphatic form, which is doubtless 
the more common in children, ends fatally sooner than the 
spleno-medullary variety. The younger the child, the shorter 
is the course and the less is the chance of recovery. 

Differential Diagnosis. — The significant facts are the enlarge- 
ment of the spleen, possible haemorrhages, and the examination of 
the blood. The main part of this examination is not merely find- 
ing a greatly increased leucocytosis, but rather the especial forms 
of leucocytes and myelocytes mentioned under the heading of 
lesions. 

Pseudo-Leucaemia (Hodgkin's Disease) 

This is a disorder which is not often seen in children. It is char- 
acterized by a more or less general enlargement of the lymphatic 
glands, hypertrophy of the spleen, the growth of lymphomata in 
the abdominal and thoracic viscera, and anaemia. In recent times 
observers have shown a tendency to regard the disease as infective, 
but the matter is as yet not definitely decided. At any rate, no 
other aetiology is able to account for all the cases ; the connection 
between this disease and tuberculosis, syphilis, and malnutrition 
seems to be somewhat fortuitous. It occurs more often in boys 
than in girls. 

Lesions. — The main changes may be found in the glands and 
the viscera. The glands may undergo a simple hypertrophy and 
retain their normal consistence, or they may assume a fibrous char- 
acter. In the former the various elements exist in their normal 
relationship, but throughout the reticulum there is present a large 
number of lymphocytes. In the latter form there is, in addition 
to the increase of cells, a notable increase in the fibrous tissue of 
both the gland and its capsule. In the spleen there may be a 
simple hypertrophy or a number of lymphoid growths. As an 



DISEASES OF THE BLOOD 343 

additional factor, there may be one or more infarcts. There may 
also be a varying number of adenoid growths in the pharynx, naso- 
pharynx, oesophagus, gastro-intestinal canal, the liver, the kidneys, 
heart, lungs, the testicles, ovaries, the thymus, thyreoid gland, 
supra-renal capsules, the dura mater, and the skin. The bone 
marrow may be altered by the growth of adenoid tissue, the heart 
muscle may fall into a condition of fatty degeneration, and there 
may be an effusion into the pleural cavity. 

Symptoms. — The attack may come in an acute or chronic form, 
but we do not know the deciding factor which predisposes to one 
course or the other. In the majority of cases there is pyrexia, 
which may remain uniformly high, may from day to day describe 
an irregular curve, or alternately appear and disappear. The 
child becomes progressively pale and more anaemic, and the 
changes in the blood are among the first symptoms. The num- 
ber of red blood corpuscles is decreased, and their form may be 
altered. In most cases there is no increase of leucocytes. The 
general effects of anaemia may be present. 

Commonly, the first sign which the parents notice is a general 
adenitis. The superficial glands are involved before the deep 
ones, and the growth generally begins on one side only. The 
cervical group is generally the starting-point ; and later on the 
submaxillary, subcervical, the mediastinal, the axillary, the mes- 
enteric, the inguinal, and even the popliteal glands may become 
attacked. The glands may be hard or soft, and may retain their 
separate form until, by the action of a peri-adenitis, a mass of 
them may be matted together. As soon as the increase in size 
becomes considerable, pressure effects of corresponding inten- 
sity may result. This is the main source of the serious symptoms, 
since the glands themselves very rarely give pain. Thus in the 
throat, the calibre of the oesophagus may be lessened enough to 
interfere with swallowing, or the larynx or trachea may be pressed 
upon, so that articulation and respiration are impeded. Hyper- 
trophy of the submaxillary and axillary glands prevents free 
motion of the respective parts. The deep glands of the chest 
may by their enlargement produce nervous congestion, cough, and 
dyspnoea. All through the body the symptoms may be explained 
by ascertaining what organs are involved, and how serious the 
functional interference is. 

There is a moderate enlargement of the spleen, but no pain. 



tm^^^^^am 



344 THE MEDICAL DISEASES OF CHILDHOOD 

The functions of the stomach and intestines may be impeded by 
lymphoid growths and the increasing weakness. The heart may 
become weak in its action, and its pulse may be irregular if the 
vagus is pressed upon. In the lungs there may be recurrent 
attacks of bronchitis, as well as an accompanying pleurisy. 
There may be a localized neuritis, following pressure, or cerebral 
symptoms from a similar cause may arise. There is always some 
anaemia, which in the later stages may become profound. In the 
prolonged form of the disease the symptoms may extend over 
months or years, until the patient dies from exhaustion or inter- 
current disease. 

Prognosis. — The outlook is bad. Some cases have recovered; 
but how and why they did we cannot say. 

Differential Diagnosis. — The enlargement of the glands may 
suggest an acute adenitis. In this condition there would be con- 
siderable local disorder, pain, inflammation, sometimes suppuration. 
Also, there will commonly be a history of a- sufficient cause. 
These signs would not be present in pseudo-leucsemia. Usually 
it is not hard to distinguish this disease from the spleno-medullary 
form of leucaemia, since in the latter there is no general adenitis, 
and the splenic enlargement is very pronounced. The enlarge- 
ment of the abdominal glands and the intestinal symptoms may 
suggest typhoid fever. But the lack of eruption, characteristic 
temperature curve, and Widal's reaction would clear the doubt. 

Treatment of Anaemic and Leucocythaemic Condition. — Although 
there may be the greatest differences between these various com- 
plaints, nevertheless the differences between their respective treat- 
ments are quite the opposite. Our lack of knowledge concerning 
even the most successful of them is undoubtedly great. At the 
same time we have a good therapeusis for most of the cases, even 
although the theory of it is not thoroughly understood. In the 
secondary anaemia of children, the first step is to remove, as far 
as possible, the primary cause. With this out of the way, the 
most important step toward health has been taken. The diet 
should be made as light and nutritious as possible (see section 
on Feeding), and the hygienic and sanitary conditions of the 
patients must be rendered thoroughly good. In the way of medi- 
cines one may give an organic preparation of iron, such as the 
peptonate, the albuminate, the malate, or the manganate. Some 
of these, notably the peptonate and the manganate, have been 



DISEASES OF THE BLOOD 345 

put up in a proprietary form that is really excellent. These 
given alone are usually efficient ; when they are combined with 
strychnine or the tincture of nux vomica, their value is enhanced. 
In chlorosis the same directions concerning diet, hygiene, and 
sanitation, must be carried out. The same salts of iron must be 
administered, and the parents must be informed of the necessity 
of continuing treatment for several weeks, as well as of the fact 
that the disease has a tendency to recur. For this reason the 
treatment must be continued until after every vestige of a patho- 
logical condition has vanished. It is a useful thing, in the second 
half of the treatment, to combine arsenic, usually in the form of 
Fowler's solution. Especially is arsenic indicated in any haemic 
disorder, where there is an enlargement of the spleen, or the 
lymphatic glands, or both. In pernicious anaemia our main re- 
liance rests upon arsenic, which may be given in increasing doses, 
from three or four drops up to fifteen or twenty, according to the 
patient's age, three times a day. In infantile pseudo-leucaemic 
anaemia arsenic is again the main drug to be used. In leucocy- 
thaemia and pseudo-leucaemia we have recourse once more to arse- 
nic, aided by iron and strychnine. In pseudo-leucaemia, as soon 
as the glands become enlarged, they should be removed by opera- 
tion. Some observers believe that the disease in the beginning is 
a purely local infection, and that in this way its progress may be 
checked. At all events, there is a diminished possibility of press- 
ure effects. As far as medicinal treatment goes, one can do no 
better than to give arsenic, to regulate the diet, exercise, and 
general mode of life, and treat the symptomatic needs. The 
iodides and mercury have also been used, but without success. 
In all these conditions there may be a wide necessity for a certain 
amount of symptomatic treatment. In those complaints which 
are characterized by marked leucocytosis and a tendency to 
haemorrhages, sufficient realization of the dangers involved in 
doing surgical operations must be had. 

HAEMOPHILIA 

This is a congenital disease which is always transmitted from 
mother to son ; the daughters usually escape the disorder, although 
through them it is perpetuated. It is the same method of trans- 
mission that is seen in gout, polydipsia, and color-blindness. 



346 THE MEDICAL DISEASES OF CHILDHOOD 

The sons of a bleeder are unable to hand on the disease to their 
children ; but his sisters and daughters are potent to transmit 
it to their sons. Summarized, the case stands thus : the boys 
in such a family bear the effects of the disease, but do not trans- 
mit it ; the girls bear no effects of the disease, but do transmit 
it. The compiled statistics of the disease gives a proportion of 
eleven occurrences in boys to one in girls. This hereditary factor 
constitutes the aetiology of the disease. There are no known 
lesions. 

There are but two symptoms : haemorrhages and arthritis. 
The haemorrhage may appear at any time of early life, even intra- 
uterine. Sometimes it shows itself at circumcision, cutting of the 
frenum of the tongue, lancing the gums, or opening an abscess. 
Usually it is not seen until the child is able to run about, for then 
he becomes liable to injuries that may cause haemorrhage. Prac- 
tically any trauma may start the bleeding ; in some cases it may 
be a scratch or a slight cut, in others the drawing of a tooth is the 
opportunity. In some cases the bleeding may be spontaneous, or 
at least have no ascertainable cause. Such cases are probably at 
the bottom of the joint affections. These children suddenly have 
pain in the knee, ankle, elbow, shoulder, or hip joint ; very rarely 
in the fingers, toes, or wrists. There are signs of effusion (doubt- 
less haemorrhage), there may be slight fever. After a time the 
effusion becomes absorbed, and the joint returns to its former use- 
ful condition, or may be slightly disabled. Repeated attacks may 
spoil its integrity. In early childhood the most frequent seat of 
the bleeding is in the nose, and the second place in order is taken 
by the mucous membrane of the mouth. As the child grows 
older, the intestines and then the stomach furnish a large number 
of the cases. But any part of the skin, mucous membranes, or 
viscera may, on sufficient provocation, be the ailing part. The 
haemorrhage varies in severity and in the time of its activity. It 
may be a mere oozing or a rapid flow ; it may last for a few hours 
or for days. It has been said that the tendency may be outgrown, 
but the unfortunate possessor of a well-marked habit does not often 
live long enough to prove it. 

Treatment. — The girls in a haemophilic family should have 
the nature of the disease explained to them, and at the same time 
be advised against contracting marriage. The advice is almost 
always neglected, but should, nevertheless, be given. Haemophilic 



DISEASES OF THE BLOOD 347 

boys should not be allowed to undergo any surgical operation, 
even so slight a one as drawing a tooth. However, in the case of 
opening an abscess, an exception may be made, because the haemor- 
rhage which is apt to ensue on spontaneous rupture seems to be 
equally great with that caused by incision. Still another excep- 
tion is vaccination, which involves little or no danger. If haemor- 
rhage exists, the best means of help lies in the use of ice and 
pressure. Styptics and the actual cautery are not to be advised. 
In the intervals between the attacks the general health should be 
fortified as much as possible. Exercise should be regulated, and 
all violent games and amusements involving exertion should be 
proscribed. 

The chloride of calcium has of late been much recommended, 
on account of its supposed faculty of causing increased coagula- 
tion of the blood. Its efficiency has not as yet been sufficiently 
demonstrated to warrant much reliance on it. Recently, attempts 
to control haemorrhage have been made by allowing normal blood 
to coagulate upon the bleeding area ; but the results are not 
encouraging. Another recent method proposed by Lancereaux, 
which gives somewhat better results, consists in the injection into 
the cellular tissue of sterile gelatine solutions (J- 2%). The 
ultimate fact remains that there is no really efficient treatment 
for a marked case of "bleeder's haemorrhage." 

Purpura 

The appearance of haemorrhages into the skin and mucous 
membranes is a sign of many diverse conditions. Some of these 
are of but little importance and fairly familiar ; others occur in 
connection with practically unknown pathological states which 
are so mysterious and obscure that various observers differ con- 
siderably in their classification of them. As research becomes 
more thorough and voluminous, purpura is seen to be merely a 
symptom which in some cases may not be the head and front of 
the disease, which moreover may eventually be relegated into a 
place of much less importance than it now holds. The classifica- 
tion given below may be regarded as provisional ; but until the 
sum of positive information is considerably greater than it now is, 
a better one is difficult to give. The cases divide themselves into 
two groups : one may be called secondary or symptomatic ; the 



■■■ 



348 THE MEDICAL DISEASES OF CHILDHOOD 

other — so far as we now know — is primary. Under secondary 
purpura are included the instances following infectious diseases, 
toxic conditions, mechanical strain, cachexia, and nervous lesions. 
The changes are generally superficial, but the element of severity 
is a large one and controls to some extent the phenomena. 

The infective group follows severe attacks of infectious 
diseases. It is difficult to say whether they represent no more 
than intensely acute attacks, or the ordinary form of the disease 
plus some foreign element. At all events we know that these 
haemorrhages occur with grave examples of these infectious 
diseases, such as measles, scarlet fever, diphtheria, malignant endo- 
carditis, epidemic cerebro-spinal meningitis, pyaemia, septicaemia, 
and other like complaints. 

The toxic group includes the effects of large doses of drugs, 
chemicals, snake venom, the absorption of poisonous matter from 
the alimentary track. The drugs which most readily produce 
this condition are the iodide and chlorate of potassium, quinine, 
phosphorus, mercury, salicylic and mineral acids. The matters 
which are absorbed from within the body include urinary and 
biliary constituents, and doubtless some unknown products of 
metabolism. 

The mechanical group consists of cases in which unusual strain 
is put upon the blood-vessels, as in cardiac disease, convulsive 
seizures, pertussis, deficient physical support of the vessels such 
as occurs in the new-born, after removing splints from limbs, and 
the like. 

The cachexia of exhausting diseases, notably the severe and 
prolonged disorders of the gastro-intestinal track, pulmonary 
system, and blood, may cause some deterioration of blood, or 
vessels, or both, that permits of superficial haemorrhages. 

The nervous group is rare in children, and appears with or 
after disease of the cord or of special nerves. 

Primary purpura may be divided into the simple form, which 
when it becomes very severe is called purpura haemorrhagica, the 
arthritic form or peliosis rheumatica, and the abdominal form, 
called Henoch's purpura. In these various conditions there are 
no constant known lesions with which we can account for the 
disease and its symptoms. Various theories have been enunciated, 
founded upon the pathology of one case or group of cases ; but 
the theories are not of general application and cannot be regarded 



DISEASES OF THE BLOOD 349 

as having passed far beyond the limits of conjecture. Thus some 
writers advance the idea that inflammatory, hyaline, lardaceous, 
or unknown changes take place within the coats of the vessels, 
and are followed by oozing through them or distinct rupture; 
others suggest a chemical agent elaborated in the body by degen- 
erative processes ; others again offer bacterial organisms as the 
causes. Each of these factors has been urged with industry and 
ingenuity, and each has failed to prove its case. At all events, 
we know that haemorrhages may occur in any part of the skin, 
mucous membranes, the solid and hollow viscera, and that in 
children the gastro-intestinal track, followed by the urinary 
system, are the oftenest affected. The frequency of occurrence 
in the other parts of the body is not by any means a matter of 
importance, since the disease is not frequent enough to allow 
compiling large numbers of cases and thereby providing a trust- 
worthy guide. 

Simple purpura occurs with or without preliminary indispo- 
sition, with or without general sickness. It appears in the form 
of petechial spots whose location is commonly seen on the legs. 
The size and shape are irregular ; the eruption may come in one 
or more crops. Its character is that of an ordinary ecchymosis, 
and when disappearing it goes through the ordinary changes that 
one sees in a bruise. The condition is usually not serious. 

There is a severe form that was formerly called purpura 
haemorrhagica, or Werlhof's disease. The haemorrhages are 
located in both skin and mucous membrane, and often are larger 
in size than in the simple form. The constitutional disturbances 
may be great, commonly taking the form of fever, disorders of 
the gastro-intestinal track, and systemic prostration. The mucous 
membrane oftenest affected is that of the nose ; but those of the 
mouth, gastro-intestinal canal, lungs, and genito-urinary system 
are also attacked ; the accompanying symptom of blood in the 
vomitus, faeces, pulmonary expectoration, or urine would naturally 
be present. Added to them would be severe prostration, anaemia, 
hemorrhagic oedema, and fever. Ulcerations of the mucous 
membranes may occur, which under the fit conditions of exhaus- 
tion may become gangrenous. In some very acute cases, called 
purpura f ulminans, the temperature is very high, the haemorrhages 
extensive ; prostration is great and is associated with serious 
cerebral symptoms. There may be an enlarged spleen and evi- 



350 THE MEDICAL DISEASES OF CHILDHOOD 

dences of nephritic involvement. It has been suggested that this 
variety of purpura is doubtless of infectious origin. It is almost 
always fatal. 

Purpura rheumatica, or peliosis rheumatica of Schoenlein, 
signifies those cases which have a joint involvement. There is 
commonly a small-sized eruption on the legs and sometimes the 
arms, and the temperature may be somewhat elevated. There is 
pain in the lower extremities, which increases at night and grows 
less in the morning. The joints, usually the knee and ankle, 
become tender, painful, often somewhat swollen, and occasionally 
the skin is reddened. This affection of the joints, added to the 
fact that among adult patients many give a history of having had 
rheumatism, has led to the beliefs that rheumatic purpura means a 
combined attack of purpura and rheumatism. Nevertheless, it is 
very probable that it should rather be regarded as purpura, char- 
acterized by haemorrhage into the joint. The fact of a former 
rheumatism may be no more than a coincidence ; and it is cer- 
tainly noteworthy that aspiration of the affected joint shows the 
presence of serum mixed with larger or smaller quantities of blood. 
The constitutional disturbance is not very great, nor is endocar- 
ditis a common complication. The disorder is not very dangerous, 
but is apt to be repeated. 

In Henoch's purpura the characteristic element is the occur- 
rence of haemorrhage into or from the abdominal organs, with 
tenesmus and pain and vomiting. There are apt to be tender- 
ness, pain and swelling of the joints ; the fever is irregular, and 
the general depression may be great. Besides the severe intes- 
tinal symptoms there may also be haemorrhages from the stomach, 
kidneys, lungs, nose, and throat. The eruption generally appears 
on the legs, and may be complicated by an outbreak of urticaria, 
or nodular, or exudative erythema. This form of purpura, unlike 
the rheumatic, occurs principally in children. 

Treatment. — The patient, even in mild attacks, should be 
confined to bed, and his environment should be made as quiet, as 
restful, and as healthy as possible. In almost all cases a tonic 
plan of treatment is indicated, with the additional means for 
relieving symptoms. Thus, an affected joint should be immobi- 
lized, and, as soon as tenderness and pain permit, may be com- 
pressed. Haemorrhage from the bowel, stomach, and lung may 
require the application of ice. The use of drugs has not given 



DISEASES OF THE BLOOD 351 

very much satisfaction. The latest one to be recommended is the 
chloride of calcium, which is supposed to check haemorrhage by 
its faculty for increasing the coagulability of the blood. It has 
not been sufficiently used to allow of an authoritative opinion 
concerning its efficacy. Arsenic in full doses is often recom- 
mended, and some cases are said to have improved materially 
under its continued use. Oil of turpentine, ergot, hamamelis, 
hydrastis, and the vegetable acids have all been used with various 
degrees of failure. Fresh fruits and vegetables have been sug- 
gested on account of a supposed relationship between purpura and 
scurvy. After the haemorrhage has ceased, iron may be pre- 
scribed. 

Prognosis. — In the milder cases, the outlook is good. In the 
severe cases the course of the disease is very trying and often 
fatal. It is very probable that more than one, possibly many, 
pathological conditions are included under the general term of 
purpura, and that with fuller knowledge a more exact idea of 
course and termination will come. At present one must be guided 
by the previous history and the character of the symptoms. 

Differential Diagnosis. — The main fact to be kept in mind is 
that the eruption does not disappear upon pressure, and that 
in the large majority of cases the precedent cause, or rather con- 
dition, may be one of those mentioned in the classification. There 
may be some doubt for a time between scurvy and purpura ; but 
a little comparison of the syndromes of the two complaints ought 
without difficulty to dispel it. 



EM 



CHAPTER XVIII 
DISEASES OF THE GENTTO-URINARY SYSTEM 

Functional Derangement of the Bladder 

The delicate equilibrium of the urinary bladder in young 
children is often disturbed by disorders of the stomach and intes- 
tines involving faulty assimilation and excretion, by conditions 
of high fever, by exposure, or by nervous weakness and excita- 
tion. It is at times nothing more than a sympathetic irritation 
brought on by disease in a neighboring part. The symptoms 
consist of spasmodic pain, of difficult and frequent urination, of 
nervous irritation, especially when the child's attention is drawn 
to the idea of urinating. 

In treating these cases, one should be careful to inquire con- 
cerning disease in any adjacent parts, such as the rectum, the 
genitals, or pelvic peritoneum, which might act as a cause. If 
such disease is present, it must of course receive immediate atten- 
tion. Likewise if the child's stomach or intestines are disordered, 
they must be treated actively and promptly. For the derange- 
ment of the bladder one may prescribe hot baths and the local 
application of heat, sedatives — bromide of soda for infants and 
tincture of hyoscyamus for older children — - and the drinking of 
much water. It must be kept in mind that in children, even pos- 
sibly more than adults, water is one of the best diuretics at our 
command. 

Acute Cystitis 

This disease is somewhat rare in children, much more so than 
in youths or adults. The smaller amount of exposure of all kinds 
to which children are subject is the cause. When it does occur 
it generally is due to irritating drugs, to vesical calculus or other 
foreign bodies, to infected urine, or gonorrhceal urethritis or vulvo- 
vaginitis. At times one is unable to ascertain the cause. 

The mucous membrane is swollen, congested, and bathed in a 

352 



DISEASES OF THE GEXITO-URIXARY SYSTEM 353 

mucoid fluid containing pus and blood-cells. The epithelial cells 
are swollen and in places disintegrated, at times so much so as to 
produce ulcerations. 

The symptoms consist of prostration, a moderate febrile move- 
ment, difficult, painful, and frequent urination, and vesical tenes- 
mus. The examination of the urine is very important, and in 
order to exclude adventitious elements of confusion the urine 
should be drawn off by catheter. When the urine is allowed to 
stand, a heavy precipitate is thrown down, and some albumin may 
be held in solution. The color is reddish, the reaction is acid, 
but with a tendency to a rapid change to alkaline. The micro- 
scope shows pus-cells, blood-cells, squamous epithelial cells, epi- 
thelial debris, and bacteria. 

The treatment consists in rest in bed, the administration of 
divided doses of calomel, the application of hot stupes or com- 
presses over the bladder, the restriction of the food to milk, and 
the use of sufficient doses of sedatives to still the pain. In 
infants the bromide of soda may be used, but in older children 
hyoscyamus may be substituted. Warm baths and local heat are 
useful. If there is any antecedent disease, it must naturally be 
carefully treated. 

Chronic Cystitis 

A chronic inflammation of the bladder may be caused by an 
extension of an acute process, by vesical calculi, foreign bodies, 
and rarely by tumors. The mucous membrane is heavy, con- 
gested, and mottled in color. There is a constant formation of 
pus, and pus-cells may infiltrate the superficial tissues. The 
mucous membrane is changed variously in different parts, being 
hypertrophied, atrophied, or eroded. With a long continued 
course, more or less connective tissue may be formed, and the 
whole bladder becomes irregularly dilated. 

The symptoms are apt to be bound up with the cause or ante- 
cedent disease. Thus vesical calculi will superimpose its own 
signs very prominently upon those of the cystitis. Ordinarily 
there are loss of flesh and strength, a querulous and irritated 
mind, frequent urination that at times may be painful. Some 
urine is always apt to remain in the dilated bladder, and there 
undergoes ammoniacal change. 

The treatment is much the same as in the acute form, with 
2 a 



maaaMmmmmMaaawwwwwBwm 



354: THE MEDICAL DISEASES OF CHILDHOOD 

the exception of frequent irrigation of the bladder with boric 
acid solutions. As soon as possible the diet must gradually be 
enlarged and the patient's strength fortified by tonics. It is of 
paramount importance that the child be examined most carefully 
in order to ascertain the existence of any pathological conditions 
which can possibly perpetuate the abnormal condition in the 
bladder. When all such factors are thoroughly known, one is 
able to judge in a fairly rational way concerning the prognosis. 

Incontinence of Urine 

This disorder is apt to be one of the most troublesome with 
which the physician has to contend. Very often, in most cases 
in fact, it is difficult to describe a cause for it, except the very 
general phrase of deficient development, or general weakness with, 
a local manifestation. This naturally does not include the cases 
of deformity or malformation of the genito-urinary organs, nor the 
functional lesions of the central nervous system of which incon- 
tinence of urine may be a symptom of long standing. In such 
cases, the weakness may involve the whole economy and be plainly 
visible in various phases of disordered secretion, excretion, and 
assimilation ; or, on the other hand, it may be more particular and 
local, while the rest of the body is fairly well nourished. This we 
often see well illustrated by deficiency in function following an 
exhausting sickness. For instance, after an attack of scarlet 
fever, the patient who formerly had had exemplary habits may be 
quite unable to control the bladder sphincter. Again, in cases of 
anaemia, a like condition may come into existence, not because 
there is any connection between enuresis and the disease in ques- 
tion, but merely because the sphincter control is one of the vul- 
nerable points in childhood. 

This is reasonable and easily understood from the common 
experience of teaching a child habits of self-control. In the ordi- 
nary course of growth, he usually learns this before he is two 
years of age ; if carefully and properly taught, he may gain this 
restraint when he is less than a year old. On the other hand, 
many a child is markedly deficient in this respect for months or 
years afterward, and the best that one can do in the way of diag- 
nosis is to claim the persistence of infantile traits, of deficient 
development. Such, of course, would not be the case where a 
rationally sufficient irritant is present : such an irritant might 



DISEASES OF THE GEXITO-URIXARY SYSTEM 355 

exist in an unusually acid urine, in a contracted or atonic bladder, 
or a bladder containing calculi, in pathological conditions of the 
uretha, in a small meatus, in abnormalities of the foreskin, in 
vulvo-vaginitis, adherent clitoris, in parasites and diseases of the 
rectum. There is one more factor, that of inheritance, which 
seems to exist in some families. Frequently enough parents, in 
stating the disability of their children, will give the additional 
information that they or their sisters or brothers had had a like 
failing. How far this is a question of true heredity or of habit, 
is always hard to say. 

Treatment. — If an antecedent removable cause exists, it must 
of course be treated vigorously : thus an adherent prepuce or 
clitoris should be freed, a narrow meatus enlarged, a long prepuce 
with an insufficient orifice amputated, a calculus in the bladder 
removed, a highly acid urine neutralized and diluted by the ad- 
ministration of alkalies and large quantities of water. A principal 
part of the treatment comes after the abolition of these precedent 
conditions ; for in the majority of cases the disorder is apt to 
continue in much the same way as before. In the first place, 
the general health must be carefully looked to ; the normal func- 
tions should be strengthened at every weak point, and the habits 
and environment of the patient regulated most scrupulously. The 
amount of water ingested in the afternoon and evening, except 
where the urine is highly acid, should be restricted, and the child 
must be ordered to empty the bladder at regular intervals which 
should not be too far apart ; likewise it is generally advisable 
for the parents, before retiring, to arouse the child and make him 
urinate. This is especially useful if his sleep is unusually heavy. 
If the bladder is contracted, so that frequent urination is a 
physical necessity, the organ may be dilated daily by warm boric 
acid or normal saline solution. 

As far as drugs are concerned, the best that one can do is to 
prescribe a combination of nux vomica and belladonna ; the latter 
drug should be given in larger doses than the former and steadily 
increased to the point of toleration. One may use either the 
tinctures or the alkaloids (strychnine and atropine) of the drugs. 
The size of the dose varies with different patients, according to 
size, weight, and idiosyncrasy. The doses may be distributed 
through the day or confined to the afternoon and evening. I 
have found no advantage in one over the other method. 



356 THE MEDICAL DISEASES OF CHILDHOOD 

These patients should not as a rule be punished for their lack 
of cleanliness. They should be regarded as sick, not disobedient, 
and punishment will be apt to diminish their confidence and self- 
respect ; they should instead be encouraged whenever praise is 
possible. For in a neurosis, such as most cases of enuresis, the 
mental condition is of great importance. 

Prognosis. — At the beginning of treatment the parents should 
be informed that this disorder is apt to be tedious, that it has an 
obstinate tendency to recur, and that the therapeutic care must 
be continued for weeks or months after the patient has gained 
a good control over the bladder sphincter. 

Vesical Calculi 

There is no doubt that vesical calculi may occur in the earliest 
as well as the latest period in life. Since the time when Lang- 
enbeck reported the finding of a stone in the bladder of a six 
months' foetus, a surprising number of cases of vesical calculi in 
young children have been diagnosticated. The cause is often 
hard to discover, and many factors have been regarded as the 
starting-point. Heredity, locality, climate, and diet have all 
been discussed in this connection. Much stress has been laid 
upon a possible lack of milk in a young child's food as being the 
frequent cause of the growth of a stone. 

These formations are generally composed of uric acid ; in 
some cases there may be an admixture of sodium oxalate and the 
urates of sodium and ammonium. Less frequently one sees cal- 
culi composed of sodium oxalate, ammonium urate, triple phos- 
phates, and other rarer salts. Usually they originate in the 
kidney, from which they are washed into the bladder, where, by 
mixing with a colloid substance, such as mucus, they are capable 
of indefinite increase. 

The symptoms may at first, especially in young children, be 
somewhat indefinite ; but careful observation will generally with- 
out much delay show the truth of the matter, Summarized in a 
general statement, they are frequent urination, exaggerated on 
brisk motion, and at times incontinence of urine, generally more 
marked during the day than at night ; the occurrence of pain, 
especially at the end of urination, referred to the under aspect 
and the end of the penis ; sudden and unexpected stoppages of 



DISEASES OF THE GENITO-URINARY SYSTEM 357 

the flow of urine when the stone is drawn to the cystic end of the 
urethra ; rectal irritation and possible prolapse of the rectum 
from straining ; the presence in the urine of mucus and pus with 
the addition at times of blood. Besides these symptoms there 
may be nervous manifestations and reflex pains in almost any 
part of the body. Thus the effects may be very widespread, and 
may even go so far as to cause mental or moral degeneration. 
This will account for some of the cases of altered character and 
disposition, for the readiness with which some of these children 
fall into habits of masturbation and precocious sexual activity. 
The examiner must not expect to obtain as typical a picture as in 
adults. Not only are the symptoms, excepting in the older chil- 
dren, not so characteristic, but also they are less continuous and 
reliable in their manner of occurrence. Almost always it will be 
necessary to observe the case for a short time before a reliable 
diagnosis can be made. 

The treatment is surgical and consists in the removal of the 
calculus either by crushing or cystotomy. In performing the 
latter operation the supra-pubic method is generally preferred. 
After the stone has been removed, careful attention should be 
given to the diet to diminish the possibility of new formations. 
The patient should drink liberal quantities of water, and highly 
seasoned foods, fats, and sugars must be avoided. The food must 
be easily digestible, and not large in amount. 

Balanitis 

The prepuce may become inflamed as the result of injury, 
excessive masturbation, collection of smegma, decomposition of 
urine held under the foreskin, and other forms of uncleanliness. 
It usually occurs in presence of a phimosis which prevents the 
retraction of the foreskin and the thorough cleansing of the head 
of the penis and the preputial mucous membrane. In dispen- 
sary practice one frequently sees an inflammation of the meatus 
which follows such causes, or even disorders of the stomach and 
intestines. As a result, the prepuce and the glans penis may 
become swollen, inflamed, cedematous, and sometimes purulent. 
The process may be cut short, or go on to sloughing and gangrene. 

The condition is treated by the application of cold or heat, and 
the injection under the foreskin of considerable quantities of a 



■■ 



358 THE MEDICAL DISEASES OF CHILDHOOD 

solution of bichloride of mercury, 1 : 8000, or permanganate of 
potassium, 1 : 500. If improvement is not rapid, the foreskin should 
be opened along the dorsum or sides, and the parts should then 
be thoroughly cleansed and treated antiseptically. After recovery 
circumcision should be done 

Phimosis 

An unusually small preputial orifice is occasionally seen in 
young boys. The younger the child, the more apt is one to find 
this condition ; and with advancing age there is a natural ten- 
dency toward a normal evolution. In some cases, however, the 
opening of the foreskin remains inadequate; as a result, and 
especially when the foreskin is long, urine may decompose about 
the glans, smegma may collect about the corona, and the prepuce 
may in some degree become adherent. A long train of widely 
divergent symptoms may follow, which show themselves in the 
way of nervous and hysterical manifestations that may attain the 
dignity of seeming perversions of character, defective growth and 
nourishment, enuresis, difficult or painful micturition, irritation of 
the sexual sense with excitement to masturbation. The range of 
effects is very inconstant as well as wide ; in one patient the 
bladder will be seriously incommoded, while in another the com- 
plaints are referred to the rectum ; in both cases the harm may 
finally become organic as well as functional. 

These cases should be taken in hand early ; where the orifice 
is not too small and the foreskin too long, dilatation may be accom- 
plished by repeated and gradual attempts to retract the foreskin 
back of the corona. When this is successful, the parts should 
immediately be put in their normal relations to avoid the danger 
of paraphimosis. Retraction should then be practised daily for 
the double reason of keeping the orifice large and the parts clean. 

In the severer cases it will be necessary to do circumcision. 
Of the two methods of treatment, excepting in trivial cases, I 
prefer the latter as being radical, rapid, and involving no tendency 
toward forming the habit of masturbation. 

Paraphimosis 

Paraphimosis is a stricture of a narrow prepuce drawn back of 
the glans penis. As a result there may be swelling, inflammation, 



DISEASES OF THE GEX1TO-URINARY SYSTEM 359 

oedema, sometimes a purulent discharge, followed in extreme 
cases by sloughing or gangrene. As soon as one sees a case of 
paraphimosis, one should immediately attempt to draw the prepuce 
into its proper position. If the swelling is too great to allow 
this, the application of cold or the use of multiple punctures of 
the oedematous tissue may give relief. If this is not promptly 
obtained, the prepuce should be divided ; on recovery, circum- 
cision should be performed. 

Urethritis in Male Children 

By far the largest number of cases of this disorder occurs 
among the children of the poor and ignorant classes, that make 
up a large part of hospital and dispensary practice ; among 
people of favorable circumstances it is, on account of their superior 
habits, much rarer. The disease appears in two varieties : a 
catarrhal and a specific. The former is due to neglect, dirt, 
adherent smegma under a long and tight prepuce, and injuries ; 
in some cases of marked malnutrition, such as rachitis, I have 
seen a simple urethritis that was subacute in its course and very 
obstinate in its resistance to treatment. Usually the general 
health required much careful treatment before the urethral 
inflammation entirely subsided. 

In the cases of specific urethritis, the cause is always infection 
with the gonococcus (Neisser). The diagnosis must regularly be 
confirmed by the microscope and Gram's method of decolorization. 
It is only in this way, as various observers have demonstrated, 
that the gonococcus can be positively differentiated from the 
diplococci commonly found the urethra. 

Gonorrhoea may occur in boys of any age ; even the new-born 
child may become infected in the process of delivery. At any 
later time of life he may contract the disease from soiled clothes 
or household utensils, from being handled or cared for by persons 
whose hands were infected, or by real or attempted sexual inter- 
course. Even very young boys may thus be exposed ; and as the 
matter may at times be of considerable medico-legal importance, a 
diagnosis of specific urethritis should be made as stated above, 
only after microscopical examination and the use of Grain's method. 

The lesions are no different from what we find in the adult, 
consisting of congestion and swelling of the mucous membrane, the 



^^^^HBM 



360 THE MEDICAL DISEASES • OF CHILDHOOD 

production of mucus and pus, and (in the specific form) the 
presence of the gonococcus, lying free in pus-cells. The in- 
flammation may extend to the deeper tissues of the penis, the 
bladder, the testicles, and spermatic cord. The prostate, partly 
on account of its rudimentary form and function, is rarely attacked 
in children. This immunity is relative, not absolute ; and occa- 
sionally in hospital practice one may meet a specific prostatitis. 
In the specific urethritis there may be a clearly defined gon- 
orrheal arthritis, the favorite seats of which are the ankle, knee, 
fingers, and wrist. 

Symptoms. — The symptoms correspond closely to those of 
the adult ; and in many cases I have noticed that young boys 
stood the strain of the disease without marked effect. In spite 
even of severe manifestations of the disease, these children have 
showed remarkable activity. The ordinary signs of discharge, of 
burning and frequent urination, of partial physical depression, 
of chord.ee, may be regularly seen in the child as well as his older 
brother. There is always a possibility of the ordinary complica- 
tions, except phimosis and balano-posthitis, which on account of 
the shape and form of the youthful prepuce are somewhat more 
liable to be probabilities in children than in adults. 

Treatment. — The boy should be confined to bed, and his 
food must be limited to fluids. The bowels should be kept open 
and the urine rendered alkaline ; the latter may be obtained by 
such simple means as bicarbonate of soda. He should have much 
water to drink, and any tendency to chordee may be counteracted 
by sufficient doses of the bromide of soda, or, in the case of older 
children with unusually great excitation, suppositories of opium. 
The penis must be kept as clean as possible, and every attempt 
must be made to prevent phimosis. If this complication occurs, 
the foreskin must be drawn back, the glans penis cleaned, the 
foreskin replaced, and the whole organ covered with hot or cold 
applications. Where the phimosis is too severe to be treated in 
this manner, the foreskin must be slit, preferably on the dorsum, 
and treated like an infected wound. On recovery of such an 
operation circumcision should be performed. Injections may be 
used early in the disease, in fact as soon as the passage of a small 
soft rubber catheter can be accomplished without too much pain. 
A number of organic preparations of silver have recently been 
manufactured for this purpose, and have been highly praised by 



DISEASES OF THE GEXITO-URIXARY SYSTEM 361 

many observers. The most useful of these, according to my 
experience, is protargol. However, in spite of one fluid or another, 
the treatment of a large number of cases is apt to convince the 
physician that the course of the disease is not thereby materially 
shortened ; and it is very possible that the old remedy of sulphate 
of zinc in a one-half per cent solution may be found worthy of use 
in almost as great degree as the newer preparations. Protargol 
need not be used in stronger solutions than a one-quarter to one 
per cent. At all events, toward the end of the disease, when the 
full discharge has been replaced by a small mucoid flow, a local 
astringent may with advantage be exhibited. The general health 
must then be protected by sufficient rest, food, and tonics. 

Complications must be foreseen as in adults. Especially 
should especial care be taken to prevent infecting the eyes. For 
this purpose the child at night should be so clothed as to prevent 
his touching the genitals. Urethral stricture may be contracted 
in the very young as well as in adults ; but it is a rare occurrence. 

VULVO-VAGIXITIS 

This condition in the female is in many ways the analogue of 
urethritis in the male. It occurs in a catarrhal and a specific 
form, the latter due to infection with the gonococcus (Neisser). 
The simple variety may be caused by poor nutrition, such as fol- 
lows the acute infectious fevers, by lack of cleanliness, irritants, 
such as inflammation of the skin with the resulting scratching, 
scabies, thread worms, injuries, and direct or indirect contact 
with other cases of this same disorder. In the specific cases, 
where the presence of the gonococcus has been demonstrated by 
the usual methods of culture, Gram's method, and microscopial 
examination, the one way of contracting the disease is hj direct 
or indirect infection from a person who has a specific urethritis 
or vulvo- vaginitis. 

The changes include an inflammation of the mucous mem- 
brane, which may extend more deeply, accompanied by the pro- 
duction of mucus and pus. The inflammation may attack the 
urethra, bladder, vagina, cervix uteri, uterus, and appendages. 
It may in unusual cases involve the glands of Bartholini and the 
peritonaeum. 

The symptoms vary according to the severity of the attack, 
and both mild and severe cases may be seen in the specific as well 



■^^^■■■■■■■Hi^H^HH^Hri 



362 THE MEDICAL DISEASES OF CHILDHOOD 

as the catarrhal variety. In the mild cases the discharge may be 
thin, watery, light yellow in color, mild in odor, and not nec- 
essarily accompanied by severe physical depression. As the 
severity increases all the symptoms become exaggerated : the 
prostration is considerable, the discharge is thick, profuse, green- 
ish yellow, and foul in odor. There are burning and frequency 
of urine, the inguinal glands may be enlarged, and as adjacent 
parts become infected appropriate symptoms appear. There are 
considerable tenderness and pain, and the general health suffers 
in various ways. The course of the disease is much longer than 
that of urethritis in the male, largely on account of the anatomical 
conformation which makes contamination of adjacent parts easy or 
inevitable. 

The treatment is analogous to that of urethritis. The urine 
should be rendered alkaline, especially if micturition is painful. 
The vulvo-vagina should be washed and irrigated two, three, or 
more times a day, according to necessity, with a solution of per- 
manganate of potassium 1 : 1000, or bichloride of mercury 1 : 8000, 
or similarly weak solutions of sulphate of zinc, nitrate of silver, or 
protargol. The choice of solution is largely a matter of individual 
preference. Usually the potassium or mercury salt, or protargol 
is used first, and then is later on followed by the zinc or nitrate of 
silver. Exacerbations or reinfections are very apt to recur. 

It is of especial importance that the child from the very onset 
of the disease should be so clothed and controlled that auto-infec- 
tion or contamination be prevented. The communicability of the 
disease must be forcibly impressed upon the parents, so that the 
child's eyes and mouth are protected and that other children are 
not endangered. 

In this disease, in making a prognosis, the possibility of puru- 
lent inflammation of the uterine appendages or the peritonaeum 
must always be kept in mind. It is of the greatest importance 
that the parents should appreciate the serious nature of the sick- 
ness and the widespread evils which it may entail. In all cases 
the long course of the disease should be predicted. 

Stricture of the Urethra in Boys 

As the result of injuries, urethritis, or balano-posthitis, the 
urethra, in boys of any age, may in one or more locations become 



DISEASES OF THE GEXITO-URINARY SYSTEM 363 

ringed with strictures. In addition to these acquired cases, the 
same disorder may occur congenitally. 

It is merely necessary to mention this subject and to state that 
the symptoms and treatment are the same as in adults. 

Orchitis axd Epididymitis 

Inflammation of the testicle or of epicliclymus is a rare disease 
in childhood, and presents no especial feature that is characteristic 
of the patient's age. It may result from injury, from operations 
in the immediate neighborhood, such as lithotomy or an operation 
for hernia, and diseases of the urethra, as gonorrhoea. A remark- 
able case that I saw a short time ago was one of specific urethritis 
in a child two weeks of age at the time of examination. He had 
evidently contracted the disease from his mother during parturi- 
tion. When I saw him, the testicle and epididymis had been 
inflamed for twenty-four hours. Orchitis may occur in inherited 
syphilis ; but it is a rare manifestation. 

The treatment is simple, consisting of prolonged rest, elevation 
of the testicle, hot applications, and the use of sedatives. 

The chronic form is extremely rare. 

Hydrocele 

Hydrocele is not an uncommon complaint in children ; what is 
more, if the disorder is promptly recognized, it is more easily 
cured than in adults. The main point in diagnosis is to differ- 
entiate clearly between hydrocele and hernia. This may be done 
by observing that in the former the tumor is translucent, that to 
the touch it feels elastic, gives a flat note on percussion, and that 
when it is reducible the tumor disappears slowly, gradually, and 
without noise. 

There are four varieties commonly recognized in males : — 

(a) Where the vaginal process is open throughout its whole 
extent, so that serum derived from it or the peritonaeum may pass 
from one cavity to the other. This form is congenital. 

(6) Although serum is in the vaginal process, it cannot flow 
into the peritonaeum, since in the inguinal canal there is a com- 
plete shutting off of the lumen. In the first form the tumor is 
long and regular in shape ; in the second, however, the circum- 
ference of the swelling is greater below than above. 



■^ 



364 THE MEDICAL DISEASES OF CHILDHOOD 

(<?) Or the fluid may be in the upper part of the vaginal 
process, for here the closure occurs about the testicle, while the 
canal remains open above it and up to the peritoneum. 

(d) The vaginal process is closed at the top and bottom. 
The serum is held in sac-like pouches. 

There may be a hydrocele of the spermatic cord, in cysts, or 
in one mass. Another, but still rarer, form of hydrocele occurs 
in the pouch of an inguinal hernia from which the knuckle of gut 
has receded. 

In girls a hydrocele of the canal of Nuck may occur, which is 
similar to hydrocele of the cord in boys. It is a somewhat rare 
complaint ; but it has no unusual features which call tor special 
mention. 

The treatment of hydrocele is simple ; when the tumor is 
reducible, a truss may be worn. If this is unsuccessful, the 
mechanical irritation of repeated aspirations will generally effect 
a cure. It is rare that one needs to perform the so-called open 
operation. 

When the hydrocele is irreducible, the fluid should be drawn 
off by an aspirator. If it recurs, one or more repetitions of the 
operation generally cure the disorder. At the same time, one 
should remember that there may be some danger of entering the 
peritoneal cavity while attempting to do no more than empty a 
hydrocele ; nevertheless this may usually be avoided if the point of 
puncture is made sufficiently low down on the tumor. In a num- 
ber of cases in infants the injection of peroxide of hydrogen, after 
the serum has been aspirated, has given me good results. 



CHAPTER XIX 

DISEASES OF THE GEXITO-URIXARY SYSTEM {continued). 
DISEASES OF THE KIDXEYS 

Acute Congestion of the Kidneys 

Causes. — Acute congestion, or a hyperemia of the kidney, 
may result from exposure, wounds and injuries, irritant or poison- 
ous drugs, the acute infectious diseases, the loss of one kidney, 
and certain more indefinite causes, an example of which is vaso- 
motor paralysis. 

Lesions. — The blood-vessels are dilated and engorged with red 
blood-cells, so that in certain places the walls permit of minute 
extravasations into the uriniferous tubules. The color of the 
renal substance is dark, and its consistence is soft. The gland 
may be increased in size. 

Symptoms. — Outside of changes in the urine there are few 
symptoms excepting those of the exciting disease. The urine is 
diminished in quantity, its color is high, its specific gravity is 
unchanged or increased, and it may contain albumin, blood-casts, 
and an increased quantity of urates. Sometimes there are no 
albumin, blood, or casts. The condition exaggerates the gravity 
of the previous sickness, and makes its symptoms stand out more 
clearly than they otherwise would. The renal congestion does 
not, however, project itself as a sharply defined disease. 

Treatment. — The treatment is that of the original disease 
with the addition of local and general heat and the exhibition of 
diuretics, especially water. Excretion by all the emunctories 
must be thoroughly promoted, and at the same time the diet must 
be made as easily digestible as possible in order to put no unnec- 
essary strain upon the kidneys. The care of the patient must be 
scrupulous and exact, for the possibilities of the condition are 
always serious. Xegiect of this precaution can make a change 
from an acute renal congestion to an acute nephritis very easy; 
and at all events a tendency to subacute or chronic renal disorders 
is in this way commonly developed. 

365 



366 THE MEDICAL DISEASES OF CHILDHOOD 



Acute Degeneration of the Kidneys 

(Synonyms : parenchymatous inflammation, parenchymatous 
degeneration of the kidneys.) 

This process is usually due in children to the acute infectious 
diseases, although almost any severe sickness with its varying 
amounts of toxines and irritating by-products of partial digestion 
may likewise act as a cause. It may occur in connection with the 
administration of poisonous doses of phosphorus, arsenic, or mer- 
cury, especially if the doses are large. It is one of the commonest 
renal troubles among children. 




Fig. 63. — Normal Kidney. X 220. 

Lesions. — The changes are for the most part confined to the 
renal epithelium, especially of the convoluted tubes. The cells 
are swollen and congested, and may contain particles of fat, or 
the products of disintegration. In severe cases this process may 
go on so far as coagulation necrosis. The dead cells then desqua- 
mate, and on recovery are replaced by new cells. 

The whole kidney may be enlarged, and exceptionally may be 
congested. 

Symptoms. — Outside of changes in the urine there are not 



DISEASES OF THE KIDNEYS 367 

many symptoms more than the original disease produces. The 
urine is diminished and may temporarily be suppressed. Its 
specific gravity is unchanged, its color may be high, and in some 
cases there may be variable amounts of albumin and casts. The 
child may complain of headaches, of general malaise, of anorexia, 
or possibly nausea and vomiting. The course of the primary sick- 
ness is prolonged, and its severity is emphasized. 

Treatment. — The treatment is that of the original disease 
with the addition of diuretics, especially water, and the applica- 
tion of heat. This last is conveniently accomplished by hot baths. 

Excretion by means of the skin and rectum as well as the kid- 
neys should be made active, and the diet must be inoffensive and 
easily digested. 

Acute Exudative Nephritis 

(Synonyms : parenchymatous nephritis, catarrhal nephritis, 
croupous nephritis, desquamative nephritis, glomerulo-nephritis.) 

This is one of the commonest forms of nephritis that we find 
in children, being frequently set in motion by the acute infectious 
diseases, such as scarlet fever, diphtheria, acute lobar pneumonia, 
measles, the severe forms of enteritis, typhoid fever, erysipelas, 
septic inflammations of serous cavities, meningitis, endocarditis, 
and similarly acute and toxic disorders. It is worth while to lay 
especial stress upon the possibility of this inflammation's arising 
from serious disorders of the gastro-intestinal track ; and this fact 
will explain why an acute exudative nephritis should follow an 
eczema, since the latter complaint is in the majority of cases pre- 
ceded by disease of the stomach or intestines, or both. In fact 
some absorption of toxic matter is at the basis of this renal dis- 
ease, either primarily or secondarily. Thus it may begin as the 
original disease, or may occur as a sequel or complication that is 
at times more weighty than the first disorder. It has been known 
to spread so rapidly among the children of a distinct locality that 
some observers believe it to be epidemic. 

Lesions. — There are, first of all, the ordinary features of an 
acute or exudative inflammation : an exudation of serum, a diape- 
desis of red cells, and an emigration of white cells. In addition 
there may be various degrees of inflammation of the epithelium, 
mostly in the cortex of the organ. In children there is rarely, if 
ever, any serious structural change, so that when the process has 
spent itself before or at death, the kidney is found practically 



368 THE MEDICAL DISEASES OF CHILDHOOD 

unchanged. On the other hand, on careful examination one will 
be surprised at the great number of white cells found in the 
stroma, the tubes, and even in the capillary veins. 

In the capillary tufts of the glomeruli the cells increase in 
size and become cloudy ; in marked cases these swollen cells have 
the appearance of considerable masses between the glomerulus 
and its capsule. The cavities of the capsules may contain white 
and red cells, and many coagulated masses of various sizes. The 
capsular epithelium may be much swollen. The tubules may be 
swollen ; their epithelium may be swollen and cloudy, in places 
ragged and torn from the wall. Coagulated matter chokes up 
the convoluted tubes in certain areas, which may also contain 
hyaline plugs, and white and red cells. The stroma may be 
infiltrated with serum, in which case the kidney will be larger 
than otherwise. In some severe cases there may be minute col- 
lections of pus in the stroma. 

Symptoms. — The primary cases are rarely seen and easily 
overlooked. And whether the cases are primary or secondary, 
the course of the disease is about the same. They are ushered in 
with a febrile movement, loss of appetite, disturbances of the 
stomach and intestines, headache, and some prostration. In the 
mild cases there may be nothing beyond this ; but the severe 
attacks steadily get worse. As the disease progresses the patient's 
weakness increases, there may be some dropsy, vomiting may be 
obstinate, the cardiac action becomes excited or exhausted, and 
anaemia increases progressively. The left ventricle may be di- 
lated, and the arterial tension heightened. There may be sleep- 
lessness, restlessness, and twitching which may become exagger- 
ated into convulsions; in other cases stupor and delirium may 
mark the late stages. 

In mild cases the urine is slightly diminished in quantity, its 
specific gravity is unchanged, it may contain small quantities of 
albumin, casts, and possibly blood. The severer cases have much 
less urine, with larger quantities of albumin, casts of various sorts, 
and larger quantities of pus and blood. Such cases may go on to 
suppression of urine. 

Some of the cases which follow severe attacks of the specific in- 
fectious fevers run a serious course. Usually the child suddenly 
becomes acutely affected, complaining of chills, headaches, and 
general prostration. He refuses food, is unable to sleep, and passes 



DISEASES OF THE KIDXEYS 369 

very little urine. There may be some drops}*, but in a fair number 
of cases it may be so small in amount that it is regarded as unim- 
portant. The cerebral symptoms become so much exaggerated 
that the)* stand out as the principal signs. There may be pains 
throughout the body, the restlessness may change to delirium, and 
finally may give way to stupor. At any stage of the attack con- 
vulsions may set in, the outcome of which is commonly death. 
The urine is somewhat diminished in quantity, its color is high, 
its specific gravity is not materially changed, and it may contain 
albumin, casts, blood, and pus. 

The treatment is the same as in acute diffuse nephritis. 

Acute Diffuse Nephritis 

Causes. — As far as serious and permanent results go, this form 
of nephritis is the most important inflammation of the kidney 
which one is called upon to treat. Usually it is secondary, fol- 
lowing severe infectious diseases, notably scarlet fever and diph- 
theria. I have known typhoid fever and acute lobar pneumonia to 
be complicated or followed by this inflammation, and doubtless 
any sufficiently toxic condition could bring about the same result. 
The primary cases are said to be caused by exposure and conges- 
tion ; at times the aetiology is very obscure. 

Lesions. — These are, first of all, the same as one sees in acute 
exudative nephritis ; in addition there is the characteristic fea- 
ture of diffuse inflammation, a growth of new connective tissue, 
which is located in the stroma. Besides this, we must reckon 
with a growth and proliferation of the capsule cells of the Mal- 
pighian bodies. The connective tissue is scattered here and there 
in the cortex in strips and patches which follow the direction of 
the arteries. In the Malpighian bodies, the growth of the cap- 
sule cells may be so great as to squeeze or even obliterate the 
tufts of vessels. 

The whole kidney is apt to be large, white or mottled, and 
congested. The changes in it have a natural tendency to per- 
manency. 

Symptoms. — The disease may begin suddenly and the symp- 
toms may be very acute ; in other cases the onset is more insidi- 
ous and may not be recognized until it has existed for a week or 
more. Also there are cases where the s} r mptoms may not show 
themselves in full force until months after the disease begins. In 
2b 



370 



THE MEDICAL DISEASES OF CHILDHOOD 



any case, the natural tendency of the inflammation is to continue 
and not to subside. It is commonly ushered in with a moderate 
febrile movement, disturbances of the gastro-intestinal track, 
supplemented at times by disorders of the circulatory system, loss 
of flesh and strength, and anaemia. Dropsy is very apt to occur 
in varying degrees in the face, legs, feet, scrotum, and serous cavi- 
ties, in the order given. The urine is scanty, of unchanged spe- 
cific gravity, of a dark color (due in part to the presence of 
blood), and contains albumin, epithelial, hyaline, granular, or 
blood casts, and may hold in solution a smaller quantity of urea 




Fig. 64. — Acute Diffuse Nephritis, showing Plasma Cell Infiltration, x 135. 



than is normal. Occasionally the casts are not present ; and as 
the disease progresses the specific gravity falls lower than it was. 

The disease may last for weeks without a great deal of change. 

Some of these cases are exceedingly severe. They may begin 
with or without a chill, but the general prostration becomes very 
marked. The child has no appetite, complains of nausea, vomit- 
ing, and disorders of the intestines. The ansemia may have a 
rapid course, the heart may be hypertrophied and dilated and give 
a hsemic murmur, and there is almost regularly a moderate or large 
amount of dropsy. The nervous symptoms are always prominent 



DISEASES OF THE KIDXEYS 371 

and sometimes painful ; they progress from irritability to restless- 
ness, then to involuntary twitchings of the extremities and face, 
and finally to convulsions. In other cases the child becomes 
stupid, falls into mild delirium, becomes comatose, and finally dies 
from uraemic poisoning. Very often there is some interference 
with vision, accompanied by lesions in the retina and optic nerve. 
The progress of the disease is fairly steady, and many of the 
seeming variations of the child's condition are due to the involve- 
ment of one organ after another in the process of exhausting 
inefficiency. 

Treatment. — In both exudative and diffuse nephritis, the 
treatment is general and symptomatic. The patient is to be kept 
in bed, the diet should be restricted to fluids, calomel may be 
administered in small and repeated doses. Counter irritation 
may be applied to the surface of the lumbar region. The urine 
should be made as bland as possible by the use of diuretics, the 
best of which is pure water. The skin should be kept active by 
means of hot baths, and the bowels should never be allowed to 
become constipated. The ventilation of the room should be as 
nearly perfect as possible, and the patient's mind must be kept 
unruffled and fairly well occupied. 

If dropsy is present, it is advisable to restrict the amount of 
fluids consumed to less than that excreted. This may require the 
substitution of an alkaline diuretic for the water that otherwise 
would be used. For the general weakness, mix vomica may be 
used with advantage. If the arteries are much contracted, nitro- 
glycerin may be given ; in case the heart is weak, one may pre- 
scribe digitalis, strophantus, or caffeine. There are some severe 
cases where the tension of the arteries is very high, the urine very 
scanty or suppressed, and the dropsy marked ; these may require 
active sweating by means of hot packs, hot baths, and hypoder- 
matic injection of pilocarpine. 

As soon as the acute symptoms have passed, an organic prepa- 
ration of iron, preferably combined with mix vomica, should be 
prescribed. The diet must be carefully restricted for a consider- 
able time — in some cases for weeks. And above all, a rigid 
supervision of the hygiene and general manner of life must be sed- 
ulously maintained until every sign of disease or weakness has 
disappeared. Often it will be necessary to continue the use of 
tonics for weeks or months. 



warn 



372 THE MEDICAL DISEASES OF CHILDHOOD 

Prognosis. — In acute exudative nephritis, the outlook, so long 
as the condition is not too seriously complicated by other diseases, 
is, on the whole, goool. The natural tendency of the lesions is to 
resolve and leave an unchanged kidney. In the diffuse form, the 
result of the sickness is much more doubtful. The course of the 
disease is longer, its nature is much more insidious, its lesions 
have a greater likelihood of becoming permanent. After weeks 
or months it may show its worst features. Nevertheless, scrupu- 
lous care, combined with childhood's marked recuperative powers, 
can do much to bring about such an equilibrium and compensa- 
tion in the kidneys, that to all intents and purposes the child may 
fully recover. 

Chronic Congestion and Degeneration of the Kidneys 

It is not easy to classify the chronic diseases of the kidneys. 
The causes are similar in all, and one condition is apt to be 
merged in another without giving very clear clinical evidence 
of the change. In chronic congestion and degeneration the dif- 
ferential diagnosis is largely pathological. And the main benefit 
in making the distinction lies in the scientific appreciation of the 
processes which affect the patient in the form of complications 
and sequels. 

Causes. — In both the origin of the disorders lies in chronic 
disease of the heart and lungs — in short, whatever interferes 
with an unimpeded circulation of the blood. Thus the various 
forms of endocarditis, dilatations of the cardiac ventricles, pul- 
monary emphysema, and septic or non-septic effusions into the 
pleural cavity are all able to act as the exciting factor. 

Lesions. — In chronic congestion the kidney at first is of ordi- 
nary size, but later on becomes large. Its surface is hard, some- 
times called "stony," smooth, and congested. The veins of the 
pyramids are congested and in places dilated. The epithelium of 
the cortex tubules is cloudy, and in places swollen and, seemingly, 
packed tightly together. The capillaries of the glomeruli are 
dilated, their walls are irregularly thickened, and the cells which 
cover them are swollen. 

In chronic degeneration there is apt to be more exaggeration 
in the alteration of size — either in the way of decrease or increase. 
The surface is smooth, the cortex is thick and of a light hue. The 



DISEASES OF THE KIDNEYS 373 

color of the pyramids is redder than usual. The epithelium of 
the cortex tubules is swollen, infiltrated with droplets of fat, 
granular, and occasionally broken down. The capillaries of the 
Malpighian bodies may be dilated, if the origin of the degenera- 
tion rests on cardiac disease. And in all cases both stroma and 
arteries are normal. 

Symptoms. — The development of these disorders is a very 
gradual one. There is a progressive loss of flesh and strength, 
the muscles become weak and flabby, the child becomes more and 
more anaemic. Disturbances of other organs are common, and 




5*A 






w 



Fig. 65. — Chronic Passive Congestion of Kidney (Casts in situ), x 135. 

may pursue an obstinate course. The stomach and intestines are 
very apt to be affected, so that the patient complains of anorexia, 
nausea or vomiting, headaches, constipation or diarrhoea. In the 
lungs there is a constant liability to bronchitis, which is the more 
persistent on account of the common irritation of the nasal and 
faucial mucous membranes. The heart easily falls into an over- 
acting condition, with exaggerated second sound, and hard pulse. 
In both conditions the main change in the urine is a diminu- 
tion of the amount excreted. Only at certain times of exacerba- 
tions it is increased ; and in chronic degeneration it occasionally 



374 THE MEDICAL DISEASES OF CHILDHOOD 

may be suppressed. In congestion albumin and easts may be 
found. In degeneration the same casts and albumin may be found, 
but in smaller amounts. 

Treatment. — In both conditions there is no specific treatment. 
The care of the original disease is the main indication, and as 
that improves, the condition of the kidneys is apt to follow. 
Every detail of nursing must be carefully ordered, and the child's 
mind be kept as quiet as possible. Digitalis must be used with 
caution, and at times may be really harmful, as it is apt to in- 
crease the pressure on the weakened capillaries of the Malpighian 
bodies. 

Prognosis. — This depends, to a large extent, upon the prog- 
ress of the original disease. If the congestion or degeneration 
continues for too long a time, it will naturally develop into a 
chronic diffuse nephritis. 

Chronic Diffuse Nephritis without Exudation 

In children the cause of this disease is always somewhat ob- 
scure, unless there has been an antecedent acute process. It is a 
rare disorder, and occurs, for the most part, in the older children. 
Like the other forms of nephritis, it may be rapid or gradual in 
its onset or course. 

Lesions. — The kidneys are generally normal in size, until the 
later stages of the disease, when the organs may become shrunken ; 
with the alteration in size the capsules grow onto the kidney 
walls in small areas, and finally are quite adherent. This form 
of nephritis is characterized by the greatest production of con- 
nective tissue, which invades not only the stroma but also the 
pyramids. As this process advances, more and more of the renal 
tissue is replaced, so that the remaining parts have an undue 
amount of work to do. 

The tubules, partly from the strain put upon them, are irregu- 
larly dilated, and their epithelium may be congested or degener- 
ated. The Malpighian bodies are in various stages of congestion 
and atrophy, and their capillaries may fall into amyloid degenera- 
tion. At the same time the larger arteries may be attacked by a 
slow sclerotic process that renders them rigid or occluded. 

Symptoms. — The first thing that strikes the observer is the 
child's poor condition. He is thoroughly anaemic, exhausted, 



DISEASES OF THE KIDXEYS 



3T5 



subject to many complicating disorders. He lacks appetite, com- 
plains of headaches, and shows the loss of flesh and strength. In 
addition to a hsemic murmur which may folloAV the anaemia, there 
is a strong likelihood of other murmurs being present that are 
symptomatic of a chronic endocarditis. The left side of the heart 
is oftener attacked than the right, and remains feeble. As a result 
of the endocarditis, emboli ma}' become located in the meninges, 
the cerebral vessels, or the viscera ; also the various organs may 
become congested, inflamed, and then give their regular symptoms 
of the respective disturbances. Thus there may be bronchitis, 




Fig. 66. — Chronic Diffuse Nephritis without Exudation ; Connective Tissue, and 
Atrophied Glomerulus. X 180. 

pleurisy, gastritis, hepatitis, and perihepatitis, and even various 
forms of neuritis. Acute attacks of uraemia may occur in minor 
or major degrees of severity, producing irritability, muscular 
twitchings, or convulsions. There is little or no dropsy ; and 
even if the pleura becomes inflamed there is less danger of a com- 
plicating effusion than in chronic diffuse nephritis with exudation. 
The urine is usually large in quantity, unless there is an acute 
exacerbation of the disease, when the amount may become very 
small. After the acute attack has passed away, the copious flow is 



M 



wm 



376 



THE MEDICAL DISEASES OF CHILDHOOD 



reestablished. The specific gravity is low, the color is not high, 
and there is a diminished excretion of urea. Occasionally there 
may be some albumin and casts, but not as a general rule. 

Treatment. — The principal line of treatment is to care for 
any precedent and concomitant disease, and to follow the needs 
which are demonstrated by symptoms. There is no specific drug 
to be recommended, but all cases derive benefit from scrupulous 
care in regulating the diet, hygiene, and general mode of life. 
Commonly we send these cases to a mild and pleasant climate, 





Vv v~*V ; ■"/,;- 

Fig. 67. — Chronic Diffuse Nephritis without Exudation. X 135. 

where there are no startling changes of heat and cold, dryness 
and humidity. 

Prognosis. — The outlook is not encouraging ; if the patient 
is in circumstances which allow the fullest attention to all his 
needs, his chances of obtaining a reasonable degree of health are 
much better than if he is cramped in means. Under all circum- 
stances the course of the disease is long and tedious, subject to 
many exacerbations and remissions, while the general tendency 
is in the direction of deterioration. 

In spite of the organic disabilities some children seemingly 
throw off the disease, and continue to live for years. 



DISEASES OF THE KIDNEYS 377 



Chronic Diffuse Nephritis with Exudation 

This form of nephritis may occasionally be seen in well-grown 
children and youths as a primary disorder. In such cases it may 
be difficult or impossible to detect the exciting cause. In the 
majority of cases, however, the disease is a continuation of an 
acute nephritis, or an exaggeration of a chronic degeneration or 
congestion of the kidney. In a few instances it may follow long 
continued disease of the bones and joints, or chronic suppurative 
processes. 




Fig. 68. — Chronic Diffuse Nephritis with Exudation. Hyaline Glomeruli. X 125. 

Lesions. — Generally the kidneys are large and their surface is 
rough in contour. The most important change is a deposition 
of new connective tissue in the stroma in gradually enlarging 
strips and wedges. At the same time the arteries may become 
thicker and less pliable than is normal, or, in advanced cases, the 
capillaries fall into a condition of amyloid degeneration. The 
epithelium of the tubules may degenerate, and the tufts and cap- 
sule cells of the Malpighian bodies may become hypertrophied. 
The nutrition of the structures may be cut off by the atrophy 
of the capillaries connected with them. 



■ 



378 



THE MEDICAL DISEASES OF CHILDHOOD 



Symptoms. — The symptoms which first draw attention to the 
case are, as a rule, apt to be the general poor condition of the 
patient, or the evidence of uraemia. He is noticeably anaemic, and 
on estimating the percentage of haemoglobin and the number of 
red blood-cells the quality of the blood will be ascertained to be 
markedly deficient. The patient's general condition is poor, show- 
ing loss of flesh and strength, lack of appetite, headache, neuralgic 
pains, sleeplessness, disturbances of the gastro-intestinal track, 
and at times disorders of the heart. In almost all cases dropsy 
of the face, legs, and serous cavities is more or less evident. 



4%\ -> 



■.-■■ 




Fig. 69. — Chronic Diffuse Nephritis with Exudation. X 420. 



Thus a pleuritis which is contracted under such circumstances 
commonly has a complicating effusion that may or- may not become 
purulent. Or the lungs on slight provocation become more or 
less oedematous. Examination of the eyes will at times demon- 
strate a neuritis or a retinitis ; and in marked cases there may be 
asthenic diseases of the lungs, especially those dependent upon 
an impeded circulation. The urine varies widely from time to 
time in its quantitative composition. As a rule the specific gravity 
is low and the amount of excreted urea is small ; but the daily 
quantity of urine changes within wide limits ; as a rule, but not 



DISEASES OF THE KLDXEYS 



379 



invariably, albumin and the various casts may be present in fairly 
large amounts, while in the acute exacerbations blood may be 
found in varying amounts. 

The symptoms rarely continue in a steady course, but increase 
and decrease quite irregularly. In this way they may go on for 
months or years with discouraging remissions and intermissions. 
Thus, some cases fall into a condition of amyloid degeneration 
which affects, not only the kidneys, but often the liver, spleen, and 
intestines as well. Here there would be a long continued course of 
sickness with many and diverse complaints that try the vitality of 




Fig. 70. — (Edema of Lung; in Chronic Diffuse Nephritis with Exudation, x 50. 

the patient and the resources of the physician to the utmost. The 
only limits to the complications seem to be the limits of the body. 
The treatment is the same as in chronic diffuse nephritis 
without exudation. And what may be said of the prognosis in 
the one variety is equally true of the other. 



Suppurative Nephritis 

Causes. — A suppurative inflammation of the kidney is a rare 
disease in children. In some few cases it has occurred without 
discoverable cause, although that is no reason why one should 



380 THE MEDICAL DISEASES OF CHILDHOOD 

put faith in the possibility of spontaneous creation. Ordinarily 
it has followed falls, blows, or wounds, the use of infected cathe- 
ters or instruments, from cystitis, or embolic infection. 

Lesions. — When due to trauma the disease varies in severity 
according to the extent of the injury. When death is not the 
immediate result, a pyogenic process may begin. Various 
amounts of tissue may break down into pus, with which necrotic 
kidney-substance and blood are mixed. The same result may be 
reached, in the course of a malignant disease, by minute emboli 
which the blood current carries to the kidneys. The abscess 
which follows may be of any size. The portion of the kidney 
outside of such a focus will be congested and inflamed, while 
inside of it one or more varieties of the pyogenic bacteria may be 
present. In the few cases of cystitis that one meets in children 
a rare complication is an extension of the inflammatory process to 
the kidneys. When the mucous membrane of the pelvis of the 
kidnejs as well as the rest of the organ, is involved, the resulting 
condition is called pyelo-nephritis. In some cases the ureter is 
likewise attacked by congestion and inflammation, and varying 
quantities of pus may clog up its lumen. 

In all these cases there are ordinary features of catarrhal 
inflammation plus the production of pus. Where the quantity 
of pus is noticeably large, we speak of the condition as pyo- 
nephrosis. 

Symptoms. — Before the disease shows itself plainly, the child 
is plainly sick, has chills, and a hectic fever. His loss of flesh 
and strength is rapid, and he is subject to disorders of the 
stomach and the abdominal viscera, as well as diseases of exhaus- 
tion and malnutrition, to anaemia, to malassimilation, to complica- 
tions that are both wide and remote. There are usually tenderness 
and pain in the lumbar region, and in some marked cases a tumor. 
The main help to diagnosis rests on the composition of the urine. 
The quantity is apt to be decreased, the reaction usually acid, 
and the presence of albumin is assured by both the inflamma- 
tion of the kidney and the varying amount of pus held in sus- 
pension. This amount may be large or small, in some cases 
merely perceptible by means of the microscope, in others so 
abundant as to make the urine opaque and turbid. In addition, 
one is fairly sure to find red and white blood-cells, broken-down 
epithelium, and epithelial cells, as well as casts and micrococci. 



DISEASES OF THE KIDNEYS 381 

If there are calculi present, as they rarely are, the particular 
symptoms which they produce will show themselves. In the same 
way, if the pyogenic process extends into or behind the perito- 
naeum, into the intestines or diaphragm, there will be correspond- 
ing signs. 

Treatment. — The medical treatment consists of rest in bed, 
neutralization of the urine by giving alkalies when it is acid and 
benzoic acid when it is alkaline, the restriction of the diet to 
fluids, and the administration of diuretics. The general care of 
the case requires much attention. If the patient does not soon 
improve, surgical help must be summoned. 

Prognosis. — The outlook is not good, but each case must be 
judged upon its merits. Children, except in the severest cases, 
recover more easily than adults. An important factor in deciding 
on the outcome of the disease is its aetiology. 

Chronic Pyelonephritis 

A chronic inflammation of the mucous membrane of the kidney 
may in rare instances occur as the result of renal calculi or a 
chronic cystitis. The mucous membrane of the pelvis and calyces 
are in a condition of chronic inflammation, there is an irregular 
production of granulations under the epithelial layer, and the 
epithelium itself is ragged and hypertrophied. There may be a 
production of serum and pus. There will regularly be a forma- 
tion of some connective tissue in the kidney. 

The symptoms show themselves in a series of exacerbations 
and remissions. When the pus and serum collect in large quan- 
tities there is more pain than otherwise, the fever rises, and a 
tumor becomes evident. The urine shows these changes in the 
quantity of pus, and there may be a history of calculi, renal colic, 
and the passing of gravel. 

The treatment is general and symptomatic unless surgical 
interference becomes necessary. 

Amyloid Degeneration of the Kidney 

This condition hardly ever occurs alone, but usually with 
similar processes in other viscera. One can scarcely regard it as 
a clearly defined disease ; on the contrary it is no more than a 
stage in gradual dissolution, a state where the characteristic 



THE MEDICAL DISEASES OF CHILDHOOD 



structure of the organs gradually fades away, and is replaced by 
a lardaceous formation that makes the kidney appear waxy and 
almost homogeneous. Its origin lies in the action of protracted 
exhaustion, such as occurs in the course of syphilis, tuberculosis, 
diseases of malnutrition, and long continued pyogenic processes. 
Thus, not only the kidneys, but also the spleen and liver, are 
commonly involved ; and the effects of the degeneration show 
themselves in a slow but steady ebbing of the vitality as well as 
the functional activity. 




Fig. 71. — Amyloid Degeneration of Kidney, showing Glomerulus. X 220. 

The ordinary changes in the kidney have a very gradual evo- 
lution. The size of the organ steadily increases at first, but in 
the later stages it becomes smaller, and loses its regular contour. 
The capsule in the beginning is not adherent ; but this fact in the 
advanced condition becomes reversed. The characteristic tissue 
gradually fades away, becomes pale, waxy, structureless, and gives 
a satisfactory reaction to the iodine test. 

There are no distinct symptoms which belong to this condition. 
Its effects are merged into those broad disabilities of the general 
complaint, in which the signs that one viscus or another con- 
tributes may have a part. The whole picture is one of progressive 



DISEASES OF THE KIDXEYS 



383 



wasting, of an almost uninterrupted loss of functional ability, and 
of steadily approaching death. 

There is no especial treatment. All that one can hope to do 
lies in the direction of general care, answering the symptomatic 
indications, and most of all prosecuting the treatment of the 
original disease. Living in a favorable climate, the use of tonics, 
the employment of massage and other mild forms of exercise, and 
the regulation of the diet, all have some value. But, no matter 
what one may do, the patient as a rule dies. 




Fig. 72. — Infarction of the Kidney. X 10. 
(Endocarditis and Broncho-Pneumonia.) 

Infarction of the Kidney 



The terminal result of renal embolism, which we call infarc- 
tion, has a keen pathological and academic interest, although its 
practical importance is not very great. When in the course of 
some grave disturbance of the circulation, such as may occur in 
endocarditis, a renal artery becomes plugged up and the area 
which it supplies is thus cut off, the effects are easily seen in the 
fan-shaped space which is thereby defined. The epithelial tissue 
thereby loses its source of nourishment, it disintegrates, its nuclei 



384 THE MEDICAL DISEASES OF CHILDHOOD 

fade and disappear, and it goes through more or less of the process 
of coagulation necrosis. The broad end of the wedge is at the 
surface, while .the apex projects into the body of the organ. The 
infarction may have a light red or yellow color, or in very recent 
cases a deep red hue. As the process of repair progresses the 
epithelial debris becomes absorbed, cicatricial tissue forms with 
the accompaniment of diminution of substance and color, and a 
limited establishment of collateral circulation. 

It has been said that the production of an infarction in adults 
is indicated by a sudden pain in the region of the kidney. In 
children, however, the diagnosis is practically never made during 
life, for these patients are generally not capable of exact and 
faithful description of their subjective symptoms. 

Perinephritis 

For various reasons an acute exudative inflammation may 
attack the loose connective and fatty tissue about the kidney. The 
process may be resolved, or go on to the formation of an abscess. 
This is called perinephritis or perinephritic abscess. 

Causes. — The inflammation may start from traumatism, ex- 
posure, or from some unknown cause. In the so-called secondary 
cases it may follow disease of the spine, suppurative disease of the 
kidney, renal calculi, abscess of the large intestine, appendicitis, 
disease of the ureters, bladder, or genital organs, and typhoid 
fever, smallpox, and other acute infectious fevers. 

Lesions. — There is at first an exudative inflammation followed 
by a breaking down of the tissue into pus. The location of the 
parts admirably favors the burrowing and draining of this pus in 
various directions. Thus the abscess may finally point in the 
lumbar muscles, or on the inner aspect of the thigh as if it were a 
psoas abscess, or by means of the sacro-sciatic notch it may appear 
in the buttock ; following another direction it may make its way 
through the urinary bladder or the peritonaeum, intestines, or 
stomach ; it has also been known to perforate the diaphragm or 
appear through some part of the pleural cavity or lungs. 

The kidney itself is at first not seriously affected, and the 
urine shows few if any changes. As the abscess grows it com- 
presses the neighboring tissues in all directions, and the kidneys 
themselves are naturally much affected. From congestion they 



DISEASES OF THE KIDNEYS 385 

pass on to inflammation, until they may finally succumb to an 
acute suppurative process. 

Symptoms. — Generally there ought to be but little diffi- 
culty in making a diagnosis of perinephritic abscess because the 
symptoms are fairly characteristic. At first the child complains 
of chills, and has a varying but generally high fever ; there may 
or may not be disturbances of the stomach and intestine. There 
are tenderness and pain in the lumbar region, sometimes followed 
by a red, swollen, and heated condition of the surface. As the 
abscess grows, there is a proportional inability to use the leg of 
the affected side ; the thigh and knees are kept flexed, and the 
main trouble seems to be in extending them. The patient, on 
standing up, is apt to rest his hand upon the knee of the affected 
side, and so bends his torso that the spine describes a curve, the 
concavity of which lies toward the affected side. If the abscess 
points in other parts of the body there will be corresponding 
symptoms. 

The urine shows no special changes except in some cases of 
injury, or where a suppurative nephritis comes to exist. Thus 
at last one may find some pus, blood, or albumin in the urine. 
But very often it is clear. 

Treatment. — Rest in bed, the administration of divided doses 
of calomel followed by a saline, and the local use of heat or cold, 
are routine practices. If there is not a subsidence of the symp- 
toms and if signs of pus formation appear, a surgeon should be 
allowed to operate. Delay is much more dangerous than the 
operation. 

Prognosis. — The outlook is surprisingly favorable, especially 
if the process is not allowed to run on so long that it involves a 
fatal perforation. 

Differential Diagnosis. — There seems to be a likelihood of con- 
fusing perinephritis with hip-joint disease. In most cases the 
doubt should not exist, for in perinephritis there is no joint ten- 
derness, motion of the hip is impeded only in the direction of 
extension, and the leg is rotated outward. In hip disease motion 
in all directions is impeded, there is considerable tenderness in the 
joint, and the muscles of the thigh are wasted. Hip disease is 
much more chronic both in its onset and its course than peri- 
nephritis. 

From cysts, tumors, and other diseases of the kidney, from dis- 

2c 



386 THE MEDICAL DISEASES OF CHILDHOOD 

ease of the spine, psoas abscess, and growths of the abdomen, this 
disease may be differentiated by a careful consideration of the 
course and character of the various affections. For none of them 
imitates very closely the course and symptomatology of peri- 
nephritis. Finally the diagnosis may be confirmed by passing an 
aspirating needle into the abscess, and withdrawing some pus or 
pus-stained fluid. This must be done cautiously and with strict 
antiseptic precautions. 

Hydronephrosis 

As a result of an impediment to the flow of urine, the kidney 
may become dilated. This obstruction may be congenital or 
acquired. In the congenital variety the cause may be an imper- 
forate ureter or urethra, a twisted or compressed ureter, or any 
malformation of the bladder which would interfere with its nor- 
mal function. These congenital cases are often associated with 
other deformities, as harelip or club-foot. 

The acquired cases of hydronephrosis may be due to calculi in 
the kidney or bladder, any stricture of the ureter or urethra by 
disease, injury, or new growth. Nephroptosis has been known to 
act as a cause. 

The pelvis and calyces of the kidney are dilated to a small or 
great degree. The fluid may be a normal or altered urine, with 
or without an admixture of pus. The fluid distends the pelvis of 
the kidney, then the calyces, and finally may so wear down the 
kidney tissue that nothing more than a mere shell is left. As the 
tumor increases in size it may give pressure symptoms in any 
direction, and may be felt on palpation through the abdominal 
wall or even in the back. If one kidney alone is affected, the 
excretion of urine may be successfully carried on by the other ; 
when both are attacked, the patient will show the signs of uraemia. 

It is possible to confuse such a tumor with a cyst of the spleen, 
liver, ovary, or kidney. Generally a careful examination will 
suffice to clear up the diagnosis. Perinephritic abscess, pyoneph- 
rosis, and hydatid cysts may be diagnosticated in part by urinary 
examination. 

There is no specific treatment for this condition except that 
of an antecedent causal disease, unless the tumor is very large or 
both kidneys are involved. Such cases call for surgical inter- 
ference. 



DISEASES OF THE KIDNEYS 



387 



Parasites of the Kidney 

Echinococcus. — In a general invasion of this parasite, mother-, 
daughter-, and grand-daughter cysts may be formed in the kidney. 
A tumor may form, attended by pain and the passage of a small 
quantity of blood in the urine. The diagnosis is confirmed by 
finding the hooklets in the urine. The treatment is surgical. 

Other parasites that have been seen, but rarely, in the kidney 
are Strongylus gigas, Filaria sanguinis hominis, Trichina cystica, 
and Bilharzia haimatobia. They lie so far from the usual expe- 
rience and practice in children that one should properly look for 
them in special works on parasites. 

New Growths of the Kidney 

In early childhood the kidney may be the seat of tumors which 
in most cases are of serious import. A very large proportion are 




Fig. 73. — Large Round-Cell Sarcoma of Kidney. X 180. 

malignant, and most of these are sarcomatous. The different 
varieties of round-celled, spindle-celled, and myo-sarcoma are 
represented ; in a much smaller percentage one may find carci- 



388 THE MEDICAL DISEASES OF CHILDHOOD 

noma or a mixture of sarcoma and carcinoma. Most of these 
tumors are congenital, and in the others the aetiology is obscure. 
A very few cases of benign growth have been recorded which 
were fibromata or adenomata. 

The symptoms are not intelligibly discernible until the growth 
has assumed a sufficient size to render discovery by palpation 
possible. In some instances its bulk becomes enormous, especially 
in the later stages of the disease. Usually, however, the doubt is 
felt only in the earliest periods. The only exception to this rule is 
the fact that in some of the cases an early microscopic examina- 
tion of the urine may show small amounts of blood-cells. The 
other symptoms are the deformity, pressure effects with their 
corresponding signs, gradually increasing malnutrition, cachexia, 
and a small amount of pain. 

The diagnosis is usually not difficult ; but the tumor of the 
kidney must be distinguished from growths of the liver, spleen, 
abdominal organs, uterus, ovaries, and from hydronephrosis. 

These cases are surgical, and their treatment is therefore 
surgical. The sooner operation is performed, the better are the 
chances of recovery. 

Renal Calculi 

Renal calculi are concretions of various sizes formed in the 
pelvis or tubules of the kidney by the precipitation of the solid 
constituents of the urine or of matters held in suspension in the 
urine. They may occur in the form of small gravel-like bodies, 
or in masses so large that they block up the ureters. They are 
found at all ages of extra- and intra-uterine life. They vary in 
composition, being composed of uric acid, of oxalate, phosphate, 
or carbonate of lime, cystin, or xanthin. Often their composition 
is complex, being made up of two or more of these ingredients. 

The cause of this precipitation is hard to state ; and although 
many explanations have been given, nevertheless none has been 
entirely satisfactory. 

Symptoms. — The small calculi may pass away in the urine 
without giving any signs. As soon as the concretions become so 
large as to pass into and through the ureters with difficulty, renal 
colic shows itself by tenderness and pain in the region of the 
kidneys ; this pain may spread in the direction of the testicles 
(which from spasm of the cremaster muscle are then tender and 



DISEASES OF THE KIDNEYS 389 

retracted), the bladder, the end of the penis, the perinseum, the 
hypogastrium, and the inner aspect of the thigh, following, in 
short, the branches of the lumbar plexus. In some cases it may 
even be referred to the opposite kidney. 

The attacks may last a short or long time; the latter cases are 
especially able to give general prostration, nausea, a rise of tem- 
perature, or even syncope. In a moderate as well as a severe 
attack the respiration is quick and shallow, the skin may be cold 
and clammy, and the face has an anxious look. 

In the urine one may find crystals, small quantities of pus, 
blood, and epithelial cells. It is passed in small amounts and 
with spasmodic frequency. 

If the ureter is occluded, hydronephrosis may result ; or from 
irritation and pressure a pyelonephritis or atrophy of the renal 
substance may result. 

Treatment. — For the relief of immediate pain, we may give 
hot baths and in older children hypodermatic injection of mor- 
phine. In addition, especially during the intervals between the 
attacks, large quantities of alkaline waters should be consumed, 
and the diet must be as largly fluid as possible. 

If the symptoms point to the presence of a large calculus, one 
that is too large to be passed, an operation for its removal should 
be urged. 



CHAPTER XX 
THE SPECIFIC INFECTIOUS DISEASES 

In the following two chapters there must necessarily be so 
many references to the lymphatic glands and their drainage areas, 
that it has seemed best to insert here a partial but satisfactory 
table of them. The adenitis that occurs in so many of the specific 
infectious diseases is by no means a matter of haphazard ; on the 
contrary there is the closest connection between the swelling and 
inflammation of the glands with diseases of the associated part. 
It is advisable to work out this connection in every case ; for not 
only do we thereby obtain additional information about the 
disease in question, but also we get new aids in differential diag- 
nosis. And most of all we are saved from the error of supposing 
that the child is sick with yet another disease. 

Lymphatic Glands, their Location and Drainage Areas l 

HEAD AND NECK 

Glands Drainage Area 

Suboccipital 



Posterior half of head. 
Mastoid 

Parotid Anterior half of head, orbits, nose, upper 

jaw, upper part of the pharynx. 

Submaxillary Lower gums, lower part of face, front of 

mouth and tongue. 

Suprahyoid Anterior part of tongue, chin, and lower lip. 

Superficial Cervical Exterior ear, side of head, and neck and face. 

Retropharyngeal Nasal fossae and upper part of pharynx. 

Deep Cervical Mouth, tonsils, palate, lower part of pharynx, 

larynx, posterior part of tongue, nasal 
fossae, parotid and submaxillary glands, 
interior of skull, and deep parts of head 
and neck, upper set of lymph glands, 
lower part of neck, and joining axillary 
and mediastinal glands. 

1 From Curnow and Treves ( Ashby and Wright) . 
390 



THE SPECIFIC INFECTIOUS DISEASES 391 

UPPER EXTREMITY 

Supracondyloid Three inner fingers. 

Axillary Upper extremity, dorsal and scapular regions, 

front and sides of trunk and breast. 

LOWER EXTREMITY 

Anterior Tibial and Popliteal . Deep lymphatics of the leg, and receive some 

vessels from the skin of the leg and foot, 
chiefly the outer side. 

Inguinal : 

Femoral set, superficial . . Superficial vessels of lower limb, and partly 

of buttock and genitals, also perinseum. 

Horizontal set, superficial . Abdomen below umbilicus, buttock, and 

genitals. The deep vessels of the lower 
limb go to the deep glands along the 
femoral vein. 

Iliac The pelvic viscera and the deep vessels of 

the genitals partly. 

Lumbar All the lower glands, uterus, testes, ovaries, 

kidneys. 

Sacral The rectum. 



■■ 



392 THE MEDICAL DISEASES OF CHILDHOOD 



Scarlet Fever 

Scarlet fever, or scarlatina, is an acute, eruptive, and infectious 
fever that is worthy of most serious consideration and study. 
Under favorable conditions its course and treatment may be very 
simple ; but on the other hand it may be difficult to recognize, 
refractory to treatment, and serious or even fatal in its outcome. 

Cause. — It is undoubtedly the result of infection by a micro- 
organism ; but what that micro-organism is and what its life 
history is, are still matters of investigation. Many attempts at 
isolating and cultivating it have been made ; and in this connec- 
tion one should refer to the outbreak of scarlatina in Marylebone, 
London, when the infection was traced through the use of milk 
obtained from a herd of cows in Hendon. The epidemic was 
practically confined to the users of this milk ; and when the cows 
that supplied it were examined they showed evidences of a cer- 
tain pyogenic disease of the teats and udders, as well as patho- 
logical changes in the viscera. From these animals Dr. Klein 
obtained a streptococcus that was similar to one found in the 
affected consumers of the milk. The validity of this claim has 
been strenuously attacked on the ground that the streptococcus 
involved was not the cause but the accompaniment of the scarlet 
fever, and that it was no other than the well-known streptococcus 
pyogenes. Confirmation of this view is given by the occurrence 
of various forms of the fever, some of which are clearly complica- 
tions of streptococcic invasion. It is undoubtedly possible that 
the so-called septic and malignant forms are merely ordinary 
cases of scarlatina plus a varying but always severe invasion of 
one or more varieties of streptococcus. The more one sees of these 
cases and the more one observes their course and complications, the 
more one is convinced that they make a picture, not merely of a 
severe eruptive fever, but also of a septicemic or pysemic disease 
grafted thereon. Examples of this may be seen in the trying and 
dangerous cases of tonsillitis and laryngitis, of cellulitis, adenitis, 
and nephritis that complicate attacks of scarlatina which otherwise 
would be comparatively simple. This view is made stronger by 
the fact that the occurrence of such complications acts in the way 
of a second infection, that they are not necessarily a part of the 
original disease, and that when they get a hold upon a hospital or 
locality a large proportion of the cases therein become affected by 



THE SPECIFIC INFECTIOUS DISEASES 393 

them. Moreover, additional evidence from another side is pro- 
vided in the good results obtained in some cases by the use of 
anti-streptococcus serum where these severe complications were 
thereby simplified or nullified. The point wherein we still are 
weak is our ignorance of streptococcus, its many possible varieties, 
the differentiation of one from another, and the consequent diffi- 
culty in the production of specific serums. 

Lesions. — In the ordinary case the pathological changes are 
simple and not many. The eruption is evidently the result of the 
absorption of toxines. There is congestion of the capillary vessels 
in the cutis vera, with a consequent swelling in the surrounding 
area. There are an emigration of white cells and a proliferation of 
round cells into the Malpighian layer. The inflammatory process 
continues in and about the sweat glands and ducts, by which the 
epithelial layer breaks down and exfoliates. When desquama- 
tion takes place a minute quantity of serum makes its way be- 
tween the superficial layers of the epidermis, whereby small scales 
are forced off. When the amount of fluid is somewhat greater 
than ordinary, the pressure may become great enough to cause 
the papule to rupture. From this point the scaling spreads out 
on all sides. 

The only other changes that belong to uncomplicated scarla- 
tina are those in the throat. Here the pharynx goes through the 
ordinary changes of a catarrhal inflammation characterized by 
congestion, swelling, emigration of white cells and diapedesis of 
red cells, proliferation of epithelium, and the production of vary- 
ing amounts of mucus and fibrin. According to the severity of 
the process, superficial ulcers may occur. The same changes 
occur substantially in the tonsils ; but here the glandular tissue 
may increase markedly in size and the follicular secretion be much 
exaggerated. 

In the ordinary simple cases the viscera are very slightly 
affected ; there is doubtless some degree of acute degeneration or 
acute inflammation which expresses itself with greater or less 
force in this organ or that, according to the circumstances of the 
case. Even without a septic element the kidney, liver, intestines, 
and glands may be adversely influenced ; but the changes have a 
natural tendency to resolve themselves, so long as the fever is 
uncomplicated. 

Of all the viscera the kidneys are the most easily affected. 



394 



THE MEDICAL DISEASES OF CHILDHOOD 



Even in the mild attacks and when the general disturbance is 
comparatively small, there is some degree of congestion and cor- 
tical cloudiness. Under the impulse of an asthenic condition, 
unhygienic surroundings, unwise treatment, or disorders of as- 
similation and excretion, this congestion easily develops into an 
acute exudative nephritis (q.v.). The lesions may be of all grades 
of severity ; they may be so slight that the symptoms and the 
urinary analysis can scarcely suggest their presence, or if there 
has been a marked absorption of toxines they may become so 
grave as to assume a hemorrhagic character, give the manifes- 





Fig. 74. — Acute Scarlatinal Nephritis. X 135. 

tations of acute uraemia, and soon result in death. In other 
cases the progress of the disease takes on a sub-acute, and finally 
a chronic, form which is characterized by the various changes of a 
diffuse inflammation. 

Symptoms. — A patient who contracts scarlet fever may have 
been infected in various ways : directly from another patient, 
indirectly from some person who has been near the patient, or 
even through a third person who obtains the infection from such 
mediate agency, from clothing, furniture, domestic utensils, books, 
toys, household animals, — in fact, practically any person or thing 



THE SPECIFIC INFECTIOUS DISEASES 



395 



that has been in the patient's vicinity, — and food or drink. The 
patient is the main source of contagion, by means of contact after 
the period of incubation, by the desquamating scales, excreted 
matter, such as faeces, urine, perspiration, discharges from the ear, 
and possibly the breath. A member of the household, the physi- 
cian, or nurse may likewise be instrumental, directly or indirectly, 
in spreading the disease ; and so volatile is the poison that it may 
be wafted from contaminated articles through considerable spaces 
of air. Moreover, this poison is very tenacious, so that rooms, 
furniture, books, and clothing may retain their virulence for weeks 




Fig. 75. — Acute Hemorrhagic Scarlatinal Nephritis: Glomerular Thrombosis. X 135. 

or months. The possibility of infection by means of such 
articles as water, milk, bread, and fruit, is well known and occa- 
sionally very fertile. 

When the patient has become infected, he goes through a 
period of incubation that varies in different cases. In the 
majority of cases the time is from two to four or five days, 
but the extreme limits are from a few hours to about two weeks. 
Remarkably short or long periods should always be scrutinized 
with suspicion. 

The onset of scarlatina is almost always sharp and abrupt. 



^mm 



396 THE MEDICAL DISEASES OF CHILDHOOD 

In most cases soreness of the throat is the first symptom shown, 
followed by vomiting, — often without nausea, — malaise, and rise 
of temperature. So constant are these symptoms apt to be that 
any combination of them, even if another aetiology seenis evident, 
should command respectful consideration. Their intensity varies 
in different cases : the vomiting may be trivial or severe, occa- 
sionally accompanied by other digestive disturbances ; the flush 
on the faucial mucous membrane may be light or deep, and the 
hard palate may be studded with few or many small red spots, 
all of which appear from twelve to twenty-four hours before the 
exanthem and continue into the second week of the disease ; 
simultaneously the associated glands may be slightly tender ; 
the temperature is in no way characteristic, and may be trivial or 
severe, slightly more than normal, or as high as 40.5° or 41° C. 
(105° or 106° F.). The amount of malaise or prostration varies 
with the severity of the attack and the vital resistance of the 
patient; in one case the child is scarcely sick, in another he is 
thoroughly prostrated, has chills, convulsions, and toxic depres- 
sion. These differences may characterize the whole course of the 
disease. 

At the expiration of a few hours or a day, rarely longer, the 
scarlet rash begins to appear, and persists for a variable period, 
which is usually about a week, but which may vary from one day 
to two weeks. One must be cautious in announcing the end of 
the eruption, for occasionally the red flush may disappear only to 
appear again. This is especially apt to happen at times of mark- 
edly deficient elimination or weak cardiac action. 

The favorite seat of the eruption is on the chest and neck, 
whence it spreads to the face and the rest of the body. Close 
inspection shows it to be made up of a great number of small red 
points, the clustering together of which gives the characteristic scar- 
let flush. There are many possible variations, both in its course of 
development and appearance : it may develop from the legs as a start- 
ing-point, or the arms, or any other portion of the body ; it may be 
heavy or sparse, deep or light colored, continuous or circumscribed, 
petechial, macular, or hemorrhagic. Nevertheless, in practically 
all cases the characteristic quality is so clearly evident that little 
or no doubt concerning it need be felt. Especially is this true, if 
one keeps in mind that with the appearance of the eruption the 
other symptoms should develop with an equal step. The throat 



THE SPECIFIC INFECTIOUS DISEASES 



397 



becomes more tender and painful, and occasionally is covered in 
part by a thin membrane ; the glands become plainly enlarged 
and tender — so much so at times that they render movement of 
the parts painful ; the tongue may be coated, the temperature 
rises, the pulse becomes correspondingly rapid, followed some- 
what laggingly by the respiration, and the skin, on account of 
itching, becomes uncomfortable. The tongue, after being coated 



PUL. 


RESP. 


TEMP. 


■ 


2 


3 


4 


5 


6 


7 


8 


9 


10 | 11 


12 i 13 


14 


15 






FAH. 


CEN. 
































170 


70 


108 


42.2 
































160 


65 


107 


41.6 
































150 


60 


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PULSE, RESPIRATION AND TEMPERATURE CHART OF SCARLET FEVER. 
AGE, 5 YEARS. 

PULSE RESPIRATION_. ^__. TFMpfpatiipf 



Fig. 76. 



on the average for a half week, clears up and assumes the well- 
known "strawberry" appearance ; the temperature, pulse, and res- 
piration begin to travel toward their normal limits ; the throat 
gradually becomes painless ; the sense of malaise steadily and 
appreciably fades away, and the child goes on to convalescence. 



398 THE MEDICAL DISEASES OF CHILDHOOD 

At this time desquamation sets in, beginning on the portions of 
the skin first affected by the rash, and being most abundant where 
the skin is thickest. It continues on these parts longest — occa- 
sionally as long as two months, while other portions of the body, 
as, for instance, the face, may be quite clear in a week. It occurs 
in the form of fine flakes that are shed in copious amounts ; on 
the fingers and toes, in other words where the skin is thick, it 
may change its form, and instead of fine flakes the skin may come 
off in patches and strips that are usually compared to sections of a 
glove-finger. In a few cases the hair and nails have been shed. 

This is a description of a mild, or, at the most, a moderate case; 
frequently the variations in intensity are noteworthy. On the one 
hand, the cases may be very mild, so much so that carelessness 
in observation will pass over them entirely until attention may 
be drawn to the desquamation, possibly to ear disease, or to com- 
plaints that are founded upon a nephritis. On the other hand, 
the children may from the very first be exceedingly sick, the 
symptoms may in every way be much exaggerated, and the dan- 
ger of the disease becomes great. These cases, according to their 
severity and the judgment of individual observers, have been 
called severe, or septic, or malignant forms. The distinctions are 
arbitrary and misleading, and subserve no good end. Rather it 
would be much clearer and much more in accord with our knowl- 
edge — even although our knowledge is small — to call these cases 
scarlet fever with bacterial complications. Upon this secondary 
infection depends, to a large extent, the severity, course, and 
outcome of the sickness. Unfortunately, our information of the 
bacteriology involved does not allow us to speak finally of the 
varieties and the possible differentiation of one from another. 
But, nevertheless, their septic character is not hard to discern in 
the prostration, the temperature, pulse, respiration, and the com- 
plicating features -presented. In one form the throat is deeply 
involved : after the disease has well begun, an intense inflamma- 
tion attacks the tonsils. They are much congested and swollen, 
small areas of membrane appear on them, and thence gradually 
spread over the pharynx and rhino-pharynx, the soft palate and 
uvula, sometimes the epiglottis and larynx, and into the Eusta- 
chian tube. The affected tissue becomes puffy, friable, and may 
break down into superficial ulcers. At the same time the fever 
rises to greater heights (40° to 40.5° C. — 104° to 105° F.), about 



THE SPECIFIC INFECTIOUS DISEASES 399 

which it describes an irregular curve, the breathing may be diffi- 
cult, and the portion of the head and neck stiff and constrained 
on account of the swelling of the affected tissues ; at the same 
time and as a predominant symptom, the signs of intoxication 
may be indefinitely great. According to the character of the 
changes in the tonsils and throat, one may speak of the inflam- 
mation as membranous, ulcerative, or gangrenous, although 
frequently the types are not sharply distinguished. 

In these severe cases one is apt frequently to see the involve- 
ment of other parts of the body. Thus the submaxillary, cervi- 
cal, and post-cervical glands become swollen and tender, and may 
later on break down into abscesses. The inflammatory process 
may extend to the cellular tissue of the neck, and the resulting 
cellulitis may be of serious import, most of all if septic absorption, 
followed by destruction of the walls of the large vessels or throm- 
bosis, be not prevented by surgical means. Following the inflam- 
mation in the throat, one frequently sees the symptoms of an 
otitis media. The younger the child, the more apt, on account of 
the anatomy of the Eustachian tube, is this to happen, especially 
when the weather is bad. In such cases there is an exacerbation 
of the fever and constitutional prostration, the child throws his 
head from side to side, places the hand from time to time on the 
affected side, and cries in a sharp, piercing voice. If the pressure 
is not relieved by paracentesis of the drum membrane, the dis- 
charge may break its way through, thereby relieving the j)ressure 
symptoms. The otitis is subject to the same course and the 
same terminations that occur outside of scarlet fever, excepting 
that, in very malignant cases, the outlook is more discouraging, 
not only in regard to the safety of the ear itself, but also as far as 
life itself is concerned. Sometimes a septic inflammation of the 
bronchi, lungs, and pleura may arise, especially in the severe 
cases, attended by the features that mark such disorders. 

In almost all cases there is some disturbance of the kidneys. 
In the mild cases, this is barely recognizable ; in the severe 
attacks, especially those which are characterized by deep intoxi- 
cation, the lesions range from acute degeneration through exuda- 
tive nephritis to a definite interstitial change whereby a greater 
or less amount of parenchyma is replaced by connective tissue. 
These serious lesions commonly do not occur until the second 
or third week of the sickness. The symptoms are described 



400 



THE MEDICAL DISEASES OF CHILDHOOD 



under the heading of diseases of the kidneys. In these cases the 
nervous symptoms are generally marked. Even in the mild 
attacks, some disturbance of the nervous centres is frequently 
encountered. Thus one can account for the chills, the pains 
in head and body, the tendency to convulsions, and the rest- 
lessness, especially at night. When the fever is very high or 



PUL. 


RESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


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15 


170 


70 


FAH. 
108 


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160 


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41.6 
































150 


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PULSE, RESPIRATION AND TEMPERATURE CHART OF SCARLATINAL NEPHRITIS. 
THIRD AND FOURTH WEEK OF SCARLET FEVER. 
AGE, 3y 2 YEARS. 
pulse_____ respiration^_._____ temperature 

Fig. 77. 

toxaemia emphatic, these manifestations may develop into dulness, 
stupor, delirium, mania, or coma. In some instances peripheral 
neuritis with consequent paralysis, or chorea, or epilepsy have 
followed. There is a rare set of scarlatinas, sometimes called 
cerebral, in which a muttering delirium, stupor, and coma are pres- 
ent from the early hours of the disease. They are characterized 



THE SPECIFIC INFECTIOUS DISEASES 401 

by very high temperatures, unusual or deficient eruptions and a 
short course of two or three days. For the most part the result 
is death. 

Another complication that occurs in from 6 per cent to 10 per 
cent of the cases of scarlet fever is an inflammation of the joints. 
This is commonly diagnosticated as rheumatism, although in 
most cases such a judgment is false. While it is quite possible 
for a scarlet-fever patient to contract rheumatism, nevertheless 
such a complication is not often seen. As a rule such attacks are 
synovitides, slight in mild cases, severe in strongly marked or 
septic fevers. In fact the degree of sepsis controls to a large 
extent the amount of disturbance in the joint, which may range 
from a simple synovitis to pysemic abscess formation. Any artic- 
ulation may be affected, although the small joints are oftener 
involved than the large ones. The history of the patient, the 
general tendency to spontaneous recovery in the light attacks, and 
the ease with which severe ones become purulent, the absence of 
the thick creamy coating of the tongue that is so generally pres- 
ent in rheumatism, and the small likelihood of a resulting endo- 
carditis, are all apt to mark off these disorders as doubtfully 
rheumatic. 

A more frequent accompaniment of this fever is some disorder 
of the gastro-intestinal track. This is generally functional, rarely 
organic. Outside of the vomiting which occurs in the beginning 
of the sickness, there may later on be vomiting as well as diarrhoea 
due to improper food, to sepsis, to uraemia, and to the inception of 
some complicating disease. Another series of attendant affections, 
but not so common, is that of the heart. Here again functional 
disorders rather than organic are the rule. In this connection, 
variations from the normal heart sounds do not necessarily signify 
endocarditis. In fact this condition as well as pericarditis is 
seen infrequently, excepting in the so-called malignant or septic 
attacks. In scarlet fever these inflammations have the same 
course as in their primary condition. In giving an account of 
the possible contingent affections, one should not forget to include 
the liability to contract eczema, which generally starts from the 
irritation produced by an acrid discharge, such as may flow from 
the ears, the nose, or even the mouth. There is nothing peculiar 
about these disorders of the skin, nor is their treatment difficult. 

Operative cases, when brought within the range of scarlet 
2d 



402 THE MEDICAL DISEASES OE CHILDHOOD 

fever, very early become infected. Many of them illustrate the 
connection of the fever with pathogenic germs, such as strep- 
tococci ; for often the children show symptoms of sepsis, but have 
no rash, and possibly no sore throat. For such reasons these 
cases have been sometimes called " atypical," although there is a 
serious doubt whether they should be at all included under the 
head of scarlet fever. On the other hand, there have been some 
unquestionable instances of this manner of scarlatinal transmission, 
but they are not apt to be as severe as the atypical ones. 

Treatment. — Prophylaxis is comprised in the phrase thorough 
disinfection. Since both patient and his apartment with its con- 
tents are capable of spreading the contagion, it follows that both 
these factors should be cut off from the outside world as carefully 
as may be. The child should be rigorously isolated until all 
traces of desquamation have passed ; in case of doubt he should 
not be allowed to live with other children for upward of a month 
and a half, or two months. All clothes and washable fabrics in 
the sick-room should be boiled for a few hours ; and to make this 
item as simple as possible, the sick-room in the beginning should 
be stripped of all superfluous carpets, curtains, hangings, pictures, 
furniture, and clothing. The nurse should be isolated from the 
family, and whenever she leaves the house should disinfect her 
hands and face, and, if possible, her hair ; she should in addition 
wear other garments than those used indoors. The physician on 
entering the sick room should don a gown, that is easily made 
from a sheet pinned or sewed into shape, and on leaving should 
disinfect his face, hands, beard, and hair. The furnishings of the 
room should be thoroughly disinfected by steam, and whatever 
articles are of little value, especially if their nature or construction 
renders them hard to cleanse, should be burnt. Most of all, the 
pillows and mattresses should be treated with scrupulous severity. 
The walls, ceiling, and woodwork must be scrubbed and washed 
down with a strong bichloride solution, the wall-paper removed, 
and the painting and papering renewed. The old-time method of 
disinfection by means of sulphur fumes is useless, and gives a false 
sense of security. 

The general care of the patient is simple. At the beginning 
of the fever the child should be placed in a bare, empty room, 
where good ventilation, directly from the window or by means of 
grate fires, can be easily obtained. The more efficient the prepa- 



THE SPECIFIC INFECTIOUS DISEASES 403 

rations for isolation at the beginning, the less trouble and regret 
does one have later. An important item is the disinfection of the 
fasces and urine, preferably by means of mixing with a strong 
solution (1 : 500) of corrosive sublimate, and the providing of 
napkins and handkerchiefs made of cheese-cloth or other cheap 
material, which may be burnt after being used. 

The patient should take a cathartic, such as a saline or small 
and repeated doses of calomel followed by a saline ; after this it 
is advisable to keep the intestines moving gently but regularly. 
A hot bath may be given at the beginning of the treatment 
whereby the rash will appear more fully, the skin will be less 
uncomfortable, and the patient much more at ease. On each 
succeeding day the whole body should be bathed or sponged with 
lukewarm water once or more times, and in case of high fever 
one may prescribe warm or cool packs or the graduated bath. 
The higher the fever, the oftener should these baths be given, ac- 
companied by cold affusions to the head and friction to the body. 
One should endeavor to forfend the depression which follows too 
long an exposure to cold, and to see to it that the child does not 
remain in a shivering condition and with cold extremities after 
being returned to bed. In the cases of hyperpyrexia, especially 
those with cerebral symptoms, much comfort may be obtained by 
the continued application of ice bags to the head. 

The nose and throat should be copiously irrigated with anti- 
septic and alkaline solutions administered frequently. There is no 
drug that acts as a specific in scarlatina, and all that one can do in 
this direction is to promote elimination by some such means as 
the compound mixture of rhubarb and soda plus nux vomica. 
The diet should be simple and fluid, and liberal quantities of dis- 
tilled or boiled water may be allowed. The complications should 
receive the particular treatment that each calls for. 

As soon as desquamation sets in, the body should be anointed 
with vaseline after each sponge bath. When the normal tempera- 
ture is restored and the patient is free from serious complications, 
the diet should be progressively enlarged and a tonic prescribed. 
For this latter purpose an organic preparation of iron is useful 
and readily borne. When the means of the family permit, 
the child should be sent into the country for a prolonged 
vacation. 

Prognosis. — The danger of scarlet fever is controlled by the 



404 THE MEDICAL DISEASES OF CHILDHOOD 

youth of the patient, his environment, the severity of the epi- 
demic, and the existing complications. Infants bear the disease 
poorly, and some statistics give a mortality of fifty per cent. As 
a rule, the older the patient, the smaller the chance of death. Up 
to the age of puberty the general average of all cases may be reck- 
oned as ranging from eight to twelve per cent. A child who was 
previously sick or weak makes a poorer resistance than one who is 
healthy and vigorous. With the presence of marked sepsis the 
danger becomes greatly exaggerated, most of all if the truth of 
the matter is not promptly recognized and considered in the 
treatment. Nothing can be more unfortunate than the view that 
these cases are scarlet fever pure and simple, but merely a more 
severe type than the ordinary. The complications carry their 
share of danger, especially the more serious ones, such as cerebral 
disease, nephritis, lung and laryngeal disease, and joint infection. 

A child suffering from scarlet fever may suffer from a relapse 
or a simultaneous attack of measles, diphtheria, chicken-pox, 
pertussis, erysipelas, typhoid, and typhus fevers. All that one 
can say is that with the severity of the new attack and the weak- 
ness of the patient, the prognosis becomes proportionately worse. 
The occurrence of typhoid and typhus fevers in this connection is 
very rare. 

Differential Diagnosis. — A difficulty in diagnosis for the most 
part depends upon an imperfect or irregular eruption. This 
difficulty exists because a somewhat similar irritation of the skin 
may be seen at times in diphtheria, the early stage in smallpox, 
in typhoid fever, in gastric disturbances, associated with urticaria, 
heat erythema, and following the use of quinine, belladonna, and 
antipyrine. The observation and history of these cases soon 
make the nature of the disorder plain, and especially if the phy- 
sician keeps in mind the characteristics and location of the scarla- 
tinous eruption, the throat lesions, the glandular involvement, the 
sharp onset of the attack, and the usual prostration. More serious 
confusion may exist when the question of differentiating scarlet 
fever from measles and rubella arises. The points of difference 
are made plain in the table facing page 424. Tonsillitis and diph- 
theria by their temperature, characteristic appearance of the 
throat, their history, and the occurrence of disease in the neigh- 
borhood and adjacent school usually are sufficient to remove doubt 
within a short time. 



THE SPECIFIC INFECTIOUS DISEASES 405 

Measles 

This disease, otherwise called morbilli, is the commonest of the 
acute infectious fevers. It has been known so long and so inti- 
mately by all classes of people, that one of its dangers lies in the 
familiarity that brings contempt. By a large part of the laity it 
is regarded as of very little importance, although the most serious 
conditions and even death itself may result from it. This is espe- 
cially true in regard to peoples to whom it is a comparatively new 
disease, and to infants under eight months of age. 

While measles is, on the whole, a disease of early childhood, 
nevertheless older children, and even adults, may become infected. 
There is no age so young or so old as to possess immunity ; even 
a babe at birth may bear the contagion, and in proportion to the 
youth of the patient the disease is dangerous. Everybody is sus- 
ceptible to the contagion of measles, which herein has a point of 
difference from that of scarlet fever ; for the latter undoubtedly 
seems to possess a liability to attack certain persons. In addition 
there are adventitious circumstances which modify the course and 
fix the character of the measles. Thus what may in one child be 
a simple disorder, easily and quickly thrown off, may in another 
be a matter of the most serious import. Measles should never, a 
priori, be regarded as a trivial disease ; on the contrary it should 
be regarded as a fertile means of physical deterioration, of opening 
the way for a large number of possible pathological effects. 

Causes. — It is generally agreed that this disease is caused by 
an infective micro-organism which as yet has not been isolated 
and described. Several investigators have at various times 
believed that they had found the bacillus in question, but time 
did not verify their claims. It is unnecessary to go into the 
details of these investigations, since their interest is in the main 
historical. 

Whatever the germ may be, it is at all events very active in 
its diffusion and certain in infection. It is believed to distribute 
its contagion from the body surface, the bronchi, mouth, nose, and 
tears. The disease is generally transmitted from the patient 
directly to the prospective victim, and rarely through the inter- 
mediary of another person, as for instance the attending phy- 
sician. In the same way the apartments of the patient, and the 
clothes and utensils which he used, do not remain contaminated 



406 THE MEDICAL DISEASES OF CHILDHOOD 

in an obstinate manner. On the contrary, on full exposure to 
light and air and with sufficient cleanliness, they easily become 
innocuous. 

Lesions. — The changes that occur in measles are located in the 
eruptive areas of the skin and in various degrees of acute exuda- 
tive inflammations of the viscera of the abdomen, thorax, and head. 
The inflammation in the skin is located, for the most part, in the 
corium and rete ; there are considerable swelling, congestion, and 
infiltration of white cells. These round cells are seen in greatest 
number around the small vessels, along the hair ducts, the follicles 
and sweat glands, and in the papillary layer. 

The other lesions are of much more importance. They con- 
sist of inflammations of the mucous membrane of the eyes, nose, 
pharynx, mouth, larynx, trachea, and bronchi, and the intestinal 
track. The kidneys may fall into some degree of acute degenera- 
tion or acute exudative inflammation, and the lymphatic glands 
may likewise be congested and inflamed. The severity and often 
the character of these changes depend upon the predominant 
bacteria present, and the power of their toxines. 

Incubation, — The average incubation period is said to be 
about ten days, but the variations in both directions are great. 
A series of cases, in one epidemic, or in one neighborhood, is very 
apt to give an individual and separate number of days for each 
child. Thus the limits extend on the one side to about four days, 
and on the other to two weeks. The eruption, as a rule, does not 
appear until from three to five days after the period of incubation. 

Symptoms. — The first signs which the parents notice are 
generally described as a " cold." There is a catarrhal inflamma- 
tion of the mucous membrane of the nose, eyes, mouth, throat, 
and bronchi, all of which give their characteristic symptoms. On 
the palate and mucous membrane of the cheeks one may notice 
a few small, dark red spots, and Koplik has described some scat- 
tered bluish macules, in the centre of which is a white point, that 
appear on the inner aspect of the lips and the opposing surface 
of the gums as much as three days before the exanthem. The 
general appearance of the child now begins to be indicative of the 
disease ; the cough becomes harsh, the face looks peculiarly 
puffed up and doughy, the fever rises, and the child complains of 
malaise and irritability. As the nose and throat become more 
and more involved, the glands in the submaxillary and post-cervi- 



THE SPECIFIC INFECTIOUS DISEASES 407 

cal regions begin to swell and be tender. There may be one or 
more chills, and the child evinces some slight prostration. 

About three or four days after the period of incubation, an 
eruption appears on the face and body. Usuall}* its first location 
is behind the ears or on the forehead ; thence it spreads to the 
face, and so makes its way to the body and extremities. This 
course is not always alike ; it may be rapid and uniform, or 
slow and uniform, or broken up by intervals of various degree. 
Likewise the eruption may be light or heavy, according to the 
severity of the attack. The rash at first is indistinct, more like 
an irregular blush with a few spots here and there ; in a short 
time it ought to give way to small, reddish, flat papules, that 
gradually become macular in form. These spots have a tendency 
to coalesce into a rough crescentic shape with a somewhat irregu- 
lar outline. A profuse eruption may fully cover the body surface, 
while a mild attack may leave many areas untouched. The 
amount of rash usually gives rise to a corresponding amount of 
swelling of the face. In those cases where the congestion about 
the small blood-vessels is very great, minute haemorrhages into 
the skin occur which go to form the hemorrhagic rash. Such an 
eruption may likewise be variable in extent. In very weak 
children the petechial points on the back and thighs may be so 
large as to merit the name of ecchymoses. A stead}* development 
of the eruption is much to be desired ; and any interference or 
retardation must be regarded with apprehension as an indication 
of unusual intoxication and consequent exhaustion. On the other 
hand, the rash may appear, run its course, and reappear. 

When the eruption has been in existence for about a day, it 
begins to fade away in the order in which it came, taking from 
less than a day to a week to disappear. Most cases clear up 
fairly well in from two and a half to four days. Until it has 
vanished the child is noticeably troubled with the swelling, 
tenderness, and itching of the skin. These symptoms are in 
proportion to the profuseness of the outbreak. When the erup- 
tion has faded away, a fine desquamation takes place, and con- 
tinues for from a few days to about two weeks. As the rash 
develops, the general sjmiptoms maintain an even pace. The 
temperature, reckoning from the beginning of the attack,, gener- 
ally assumes a double maximum curve ; by the end of a da} T and 
a half or two days it mav amount to 38.5° or 39° C. (101.2° or 



408 



THE MEDICAL DISEASES OF CHILDHOOD 



102.2° F.), it then drops a variable amount only to ascend again 
at the height of the eruption to 39.5°, 40° or 40.5° C. (103°, 104°, 
or 105° F.) Therefore one speaks of the initial and the erup- 
tive fever. Various elements, such as complications, surround- 
ings, and the patient's vitality, may to some extent modify these 
curves, but even under such disturbing factors one can often dis- 



PUL. 


?ESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


170 


70 


FAH. 
108 


CEN. 
42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


41.1 
































140 


55 


105 


40.5 




/ 


\ ! 


.A 

v v 


A 


I 




















130 


50 


104 


40.0 


1 
/ 

/ 




V 


V 


A 




A 

f \ 

\ 


















120 


45 


103 


39.4 


/ 

/ 
J 


r 


N 






\ 
V 


A' 


\/ 


\ 
\ 














110 


40 


102 


38.8 


; 
/ 
L 


i 

i 










y 


A - 


A i 


i 

\ 












100 


35 


101 


38.3 


in 


i 

i 












V 


V 


Vv 


A 


A 








90 


30 


100 


37.7 


1 


















\ 

V 


\ 
\ 


/ \ 








80 


25 


99 


37.2 






















\ 
1\ 


A 


/ 






70 


20 


98.6 


37.0 
























AV 


/ 






98 


36.6 
































60 


15 


97 


36.1 







































































PULSE. RESPIRATION AND TEMPERATURE CHART OF 'MEASLES. 
AGE, 4 YEARS. 

PULSE ^- t-_„„ TFMDPBATI1PF °"""" Tln " 



Fig. 78. 



tinguish the general plan. After this the fever as a rule gradu- 
ally subsides to the end of the disease. Defervesence may come 
suddenly, as by crisis, when there may be some degree of collapse ; 
as a rule, however, it occurs slowly and more or less regularly. 
The pulse and respiration generally follow the variations in tem- 
perature. The progress of the other symptoms depends very 



THE SPECIFIC INFECTIOUS DISEASES 409 

much upon the degree of toxicity, the vitality of the patient, 
and the character of his environment and care. The question of 
toxicity is not, as a rule, sufficiently considered. To it the worst 
effects of the disease are due, and, what is of still greater im- 
portance, by it the liability of contracting complications is con- 
trolled. A person in a state of disease is peculiarly liable to the 
attack of related sicknesses, and in measles the various affected 
organs very easily fall into a more serious condition. Thus the 
mouth, pharynx, and larynx, that in the beginning suffer from a 
mere catarrhal inflammation, may easily be invaded by specific 
bacteria, and membranous or true diphtheritic inflammation 
is the result. The case would then, in addition to its original 
symptoms, have the modifying influences of the newly added 
element. 

Under the stress of the disease, the mouth likewise may con- 
tract a more or less serious infection, ranging all the way from a 
parasitic stomatitis to noma. Such a stomatitis is particularly 
liable to take place in the sulcus between the lips and the teeth. 
Small pieces of white membrane may dot the mucous surface, giv- 
ing way in time to small erosions, having a tendency to flow 
together. From these ulcers the Staphylococcus aureus may be 
isolated. The trachea in its turn may be attacked, and provide a 
path for the downward spread of infection. This organ has a 
marked danger in the diphtheria that complicates measles, since 
a common location of the false membrane is on the larynx. 

In the lungs we find the commonest and the most serious of 
these changes. The original condition is one of bronchitis, not 
necessarily of a serious type, excepting in very young infants 
whose anatomical configuration of the lungs tends to the involve- 
ment of the finer capillary tubes. From the mouth, nose, or 
inspired air are taken various pathogenic germs, such as strepto- 
coccus, staphylococcus, and the pneumococcus, which find a fertile 
culture-ground in the affected tissue ; and some degree of true 
pneumonic inflammation is very apt to result. This may take 
the form of a serious bronchitis, or a broncho-pneumonia of varia- 
ble extent and severity, or a true lobar pneumonia. The bronchi- 
tis may be ordinary in character, or may have a spasmodic, suffo- 
cative element that lessens as soon as the eruption has fully 
developed. The broncho-pneumonia bears even more the gen- 
eral appearance of a secondary infection, and its frequency of 



410 



THE MEDICAL DISEASES OF CHILDHOOD 



occurrence is in proportion to the obstacles in the way of wise 
treatment and hygienic care. 

The stomach and intestines are regularly affected, but the 
intestines seem the more liable to serious disorder. The condi- 
tion assumes the type of a sub-acute derangement, with mucoid, 
offensive movements. When this condition occurs before the 



PUL. 


RESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


ii 


12 


13 


14 


15 


170 


70 


FAH. 
108 


CEN. 
42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


41.1 








/ 
/ 


\ 


V 


\ A 
y \ 


















140 


55 


105 


40.5 






fS 




J\ 




\ 


V J 

\/ 


\ 














130 


50 


104 


40.0 






/ 

/ 
/ 


-1 

i 




L . 


i 


f N 


i 


\ 

\ 
\ 












120 


45 


103 


39 4 


/ 


/ 
/ 
/ 




i , 




V 


V 




\ \ 


\ 

\ 
\ 
V 


^ 


/ 

/ 


\ 
\ 






110 


40 


102 


38.8 


1 
1 
1 
1 






1 / 

y 










\ \ 


V 






\ 
\ 




^ 


100 


35 


101 


38.3 


t 


\ 


l\ 


■ 












^>L 












90 


30 


100 


37.7 


i 


V 




1 














Yjy 


kA, 

> 


\ 






80 


25 


99 


37.2 


1 / 
























\ 


A*^ 


Y^, 


70 


20 


98.6 


37.0 
































98 


36.6 
































60 


15 


97 


36.1 







































































PULSE, RESPIRATION AND TEMPERATURE CHART OF MEASLES) 
ACUTE .BRONCHO-PNEUWLONIA. 
AGE, 2 YEARS. 
PULSE RESPIRATION—.—.. — . Tr "" cr " Tn " c 



Fig. 79. 



eruption is fully developed, especial attention must be paid to it 
with the view of preventing the more serious organic lesions of 
the ileum and colon with an accompaniment of prostration. 

Among the rarer conditions is an inflammation of the vulva ; 
in badly nourished children who are not kept clean, a vulvo-vagi- 



THE SPECIFIC INFECTIOUS DISEASES 411 

nitis may follow. In its worst form, the inflammation may 
become gangrenous. The result is then usually fatal. 

An otitis, from infection through the Eustachian tube, happens 
more frequently in children than in adults. The main danger is 
the possibility of an extension to the mastoid cells. If the inflam- 
mation and effusion in the middle ear are great, paracentesis may 
be necessary. The symptoms are the usual ones of middle ear 
disease. In the inflammation of the eyes, there are no features 
that are peculiar to measles. 

The kidneys are usually affected in no serious degree, and the 
graver forms of nephritis need not be apprehended where the 
child's environment is fairly good. The heart and pericardium 
are also rarely involved, and in the same connection one may 
mention severe skin diseases, mental, and nervous disorders. Still 
less frequent are sudden haemorrhages from mucous membranes. 

Especial importance should be laid upon the possibility of 
tuberculosis as a complication or sequel, most of all in children 
who are weak or of the tubercular predisposition. In measles, 
glandular enlargement is a common condition ; when this enlarge- 
ment persists after the other symptoms of the disease have sub- 
sided, there is always cause for apprehension. But the attacks of 
tuberculosis may be widespread, so that any part of the body may 
be involved. Either these complicating attacks may come during 
the immediate convalescence, or they may be deferred until weeks 
or months afterward. At all events the utmost care should be 
exercised to forestall or ward off this danger. 

Treatment. — The preventive measures consist in isolating 
the patient for at least three weeks, and in the thorough cleansing 
and disinfection of his apartments. The room and all its furni- 
ture should then be exposed for two weeks to the fullest light and 
air. After this, danger may be supposed to have been outlived. 
One should keep in mind that the patient's person, even in the 
earliest stages of the disease, is a more fruitful source of conta- 
gion than his apartment, and that the germ of the disease is not 
so tenacious of life as that of other fevers, for instance, scarlet 
fever and diphtheria. 

The treatment of the disease itself is symptomatic and general 
rather than specific. While nothing can be done to check or 
diminish the course of measles, still we may accomplish much in 
the way of conserving strength, warding off complications, and 



412 THE MEDICAL DISEASES OF CHILDHOOD 

making convalescence easy and comfortable. As soon as a diag- 
nosis — or even a probable diagnosis — is made, the gastrointes- 
tinal track must be emptied and the patient confined to bed. The 
room should be kept cool and dark, and the eyes, if their irritation 
is great, should be irrigated with a boric acid solution, and treated 
with ice cloths. The diet should be restricted to fluids, and 
water should be given in liberal quantities. An item that I 
consider of great importance is the thorough cleansing of the 
nose, mouth, and throat, preferably with an antiseptic alkaline 
fluid, such as made from Seller's tablets. In place of this, one 
may use a saturated solution of boric acid with peroxide of hydro- 
gen in the proportion of two to one. These fluids may be used 
in an ordinary atomizer ; and in order to be of definite use, they 
must be administered with a liberal hand. Their value in pre- 
venting complications of the ears, nose, throat, mouth, larynx,, 
trachea, and lungs, and even the gastro-intestiual track, is not 
easily overestimated ; also at the same time they contribute mate- 
rially to the patient's comfort. 

If the rash is tardy or halting in appearing, a hot bath 
will materially hasten its eruption. The patient should then 
be bathed one or more times daily in lukewarm water. This 
alone will make him feel lighter, fresher, and his skin less irri- 
table than otherwise ; in addition, after the bath, he may be 
anointed with a small quantity of vaseline. 

The control of fever and irritable cerebral symptoms may be 
left to hydro-therapeutics. The graduated warm bath and cool 
packs applied to the body are, in almost every case, efficient; 
especially is this so if they are thoroughly and liberally employed. 
It is wise practice to use cold affusions to the head and heat to 
the feet. The latter precaution should be observed after every 
bath or pack, most of all if there is any depression or deficient 
circulation. 

The medicinal treatment is simple ; if there are no especial 
indications, one's attention may be directed towards promoting 
glandular activity by the administration of such means as the 
compound mixture of rhubarb and soda, with or without nux 
vomica. Individual symptoms will call for special prescriptions : 
the cough may need a sedative mixture, as bromide of soda for 
infants, or the deodorated tincture of opium for older children; 
the diarrhoea may call for liberal doses of bismuth subgallate. 



THE SPECIFIC INFECTIOUS DISEASES 413 

The sick-room should be kept cool and dark, and when possible 
one room should be used in the day and another at night. The 
physician should see to it that the temperatures of both rooms are 
about the same. The freest possible ventilation should always 
be maintained. The child's bedclothes and nightgown should be 
changed night and morning, and under ordinary circumstances he 
should not be overburdened with blankets. Mentally and phy- 
sically he should be kept as comfortable as possible. 

Prognosis. — In robust children, over two or two and a half 
years of age, whose surroundings are favorable, measles is gener- 
ally not a serious disease. On the other hand, weak children, those 
with a tubercular history or predisposition, children who live in asy- 
lums or in circumstances of ignorance, uncleanliness, and stupidity, 
find in it a frequent cause of prolonged sickness or even death. 
According to some statistics more than fifty per cent of children 
under one year of age, who suffered from measles, died during or 
shortly after the attack ; while those from five to ten years of age 
lost but little more than two per cent. The same rule may, in a 
general way, be distinguished in almost all mortality tables, and 
variations in one direction or another are the result of adventi- 
tious circumstances. In a fair grade of private practice the 
deaths should not average more than one and one-half per cent. 
In asylum practice it may easily amount to six or seven per 
cent. 

The more carefully we try to prevent and diminish complica- 
tions, the smaller will the death-rate be; this holds good with 
especial force to the danger of tuberculosis. The physician 
should endeavor to impress upon his patients the necessity of 
looking upon the potentialities of measles with respect, that the 
disease may prove to be more than a passing inconvenience, 
and that only by rigorous care are they able to minimize 
its dangers. 

Differential Diagnosis. — A typical case of measles is hard to 
mistake ; but all cases are not typical, and so the disease has been 
■confused with acute eczema, rubella, scarlatina, varioloid, and 
•copaiba eruption. The catarrhal symptoms in the throat, nose, 
and eyes, the enanthem or eruption in the mouth, the history of 
infection, and the development of the disease, which a few hours 
will bring, are entirely sufficient in almost every case to clear up 
any doubt. 



414 THE MEDICAL DISEASES OF CHILDHOOD 

Rubella 

This disease, sometimes spoken of as German measles or 
rotheln, has as its main symptoms a rose-red rash of short dura- 
tion, long incubation, slight prodromal signs, mild course, and 
almost no complications. It may occur sporadically or in epi- 
demics, and is often mistaken for slight attacks of scarlet fever or 
measles. 

Cause. — It is commonly believed to be due to infection by a 
specific micro-organism, which as yet has not been isolated and 
described. This germ attacks infants and adults rarely ; neverthe- 
less one must keep in mind that these persons are not exempt. 
About five years ago I saw a well-marked case in a young man of 
twenty-two years of age. 

Symptoms. — The main signs of the disease appear after an 
incubation period of from one to three weeks or more. There is 
often considerable difficulty in fixing the beginning of this period 
on account of the slight s}^mptoms. Different observers give 
varying accounts of this item. However, the incubation period 
toward its end is characterized by slight fever that rarely rises 
above 38.5° C. (101.3° F.) and a slight or moderate enlargement 
of the post-cervical glands, some malaise, and in a rare case a 
perceptible irritation of the mucous membrane of the throat 
and eyes. 

A few hours later the eruption appears in the form of a small or 
moderate number of pink or rose-red papules that at first are con- 
fined to the face, or to the forehead, or behind the ears. The 
intensity of the color varies in different cases, disappears on press- 
ure, and on fading leaves a light brown pigmentation for a short 
time. The papules may be almost flat or, in well-marked cases, 
somewhat raised. They are usually well scattered, but in their 
developed form may flow together and form red patches. In 
exceptional cases the eruption appears first on the body or in the 
mouth. Later on a part or the whole of the surface may be 
covered with a fine, blush-like redness. There is no subjective 
irritation of the skin connected with the rash. 

When these maculo-papules are at the height of the efflores- 
cence, the temperature reaches its climax. Not often does it pass 
38.5° or 38.8° C. (101.3° or 102° F.). At the same time whatever 
additional symptoms belong to the case reach the fullest develop- 



THE SPECIFIC INFECTIOUS DISEASES 415 

ment. These may be some bronchitis, some suffusion of the eyes 
— commonly called pink eye — without photophobia, possibly a 
slight soreness in the throat, or some glandular enlargement along 
the sides of the neck, under the angle of the jaw, and in rare cases 
in the groin. There may or may not be noticeable depression, and 
often the patient can scarcely be called sick. 

The eruption, after lasting one, two, or three days, begins to 
fade rapidly, and the child immediately feels almost well ; what- 
ever disability remains is for the most part a slight weakness. In 
some cases a fine desquamation, usually small in quantity, begins 
as soon as the eruption fades, and may continue for a week or less. 
Often there is no recognizable scaling at all. 

The gastro-intestinal track seems not at all to be affected, nor 
are any sequels or complications usual. The occurrence of dis- 
ease of the ej^es, throat, and ears may be regarded as much in the 
way of a coincidence as a result. The only children that are 
endangered by rubella are those who are very weak or sick at the 
time with some serious disorder, such as tuberculosis. 

Treatment. — All that we need to do for these cases is to clear 
out the gastro-intestinal track, restrict the diet to fluids, keep the 
patient in bed for about a week, and give daily baths. It is rare 
that one meets indications for further treatment. 

The patients should be isolated as soon as the disease is recog- 
nized or suspected. They should be kept in seclusion for at least 
three weeks, and even those who have come in contact with them 
before the diagnosis was fully made should be sequestered for a 
like period. The bodies of the patients, as well as their apart- 
ments and clothing, should then be disinfected. 

After recovery the patient may be benefited by a tonic. 

Differential Diagnosis. — The main points of distinction between 
rubella on the one hand, and measles and scarlet fever on the other, 
are the history of infection, the mild symptoms, the lack of 
marked catarrhal inflammations, the eruption, the time when the 
enanthem appears, and the absence of high fever and complications. 

Varicella 

Chicken-pox is a highly infectious disease, commonly seen in 
young children, and caused by a specific micro-organism which as 
yet is not known with certainty. Bareggi reported investigations 
in the course of which he isolated an ovoid coccus from the white 



416 THE MEDICAL DISEASES OF CHILDHOOD 

blood corpuscles of patients who had gone as far as the fifth day 
of the disease. He stated that by means of cultures of this 
micrococcus he inoculated children with varicella. Before we 
can regard the matter as definitely settled, further information is 
needed. 

The disease may be communicated by contact with the patient, 
indirectly through persons who have been in communication with the 
patient, with infected articles of clothing or furniture, and possibly 
through the air n^ar the patient. After exposure a period of about 
two weeks is required before the disease shows itself, the limits of 
incubation being from eleven to seventeen days. 

Symptoms. — In the majority of cases there are no prodromata. 
The child may not at all feel indisposed until the rash appears. 
On the other hand, in unusually heavy attacks there may be some 
little malaise, nausea, and possibly a slight rise of temperature. In 
very rare cases severe prodromal symptoms have been reported. 
The usual experience, however, is that the child is not considered 
sick until the eruption appears and thus heralds the fact. The 
rash consists of several crops of small rose-colored macules usually 
scattered over the chest, back, and arms, and the mucous mem- 
brane of the mouth and throat. Thence they may spread to 
the face, scalp, and legs. The spots on the body are apt to be 
irregularly oval, while on the extremities they approach the more 
nearly round form. In some instances the order of appearances is 
changed, the face or other part being first affected. The macules, 
the number of which is rarely large, have often a\pink or reddish 
areola, and become decolorized on pressure. A few hours after 
appearing they become hard, change into papules, and then into 
vesicles. These changes take place so rapidly that a patient on 
almost any day of the eruption shows all three stages. The 
vesicles are smaller than the macules, have a very thin covering, 
are unilocular, and are filled with a very clear, alkaline serum. 
Their appearance is so characteristic as to remind one of an old 
and good comparison to small white blisters raised by scattering 
drops of boiling water on a tender skin. The covering of these 
vesicles may rupture, and a part or a whole of the contained fluid 
may escape, leaving a depression or umbilication in the centre of 
the structure. Some of these formations become covered with a 
crust, while underneath them a small pyogenetic process may exist. 
This leads to a variable amount of ulceration with a resulting scar. 



THE SPECIFIC INFECTIOUS DISEASES 417 

In the well-marked cases there is doubtless an element of local 
infection with pus-forming germs such as might attack a similar 
small wound. Reports of hemorrhagic and gangrenous varicella, 
especially in tuberculous children, have been made, but they are 
exceedingly rare. Their names sufficiently describe them. 

The eruption lasts from two days to two weeks, according to 
the virulence of the infection and the number of crops of the rash. 
The disease is communicable from the first outbreak of the spots 
until desquamation has been completed. 

The complications are not dangerous so long as the child is 
well cared for. The open wounds produced b} r the rupture of the 
vesicles gives an opportunity, as stated above, for infection. In 
this way erysipelas has been known to supervene. Diseases of the 
kidneys, lungs, and nervous system may occur, but they are rare. 

Treatment. — All that one need do consists in making a diag- 
nosis and supervising the general care of the patient. The gastro- 
intestinal track should be emptied, the patient confined to bed, the 
diet restricted to fluids, and the body bathed or sponged daily. In 
case the fever mounts to an uncomfortable height, cold packs or 
the graduated cold baths may be ordered. Any restlessness or 
delirium may be relieved by the use of ice bags to the head. If 
the skin itches to an uncomfortable extent, it may be sponged fre- 
quently, and then anointed with vaseline or lightly covered with 
a dusting powder. 

Complications should be treated according to their needs. 

Differential Diagnosis. — Confusion of varicella with skin dis- 
eases is not apt to occur after the ph} T sician's first visit, for the 
latter give no fever and have no enanthem. The history, the 
manner of eruption, the simultaneous existence of macules, 
papules, vesicles, and crusts, the occasional pitting of scattered 
vesicles, the appearance of the enanthem, all these mark off 
varicella from the other eruptive fevers. See table facing p. 424. 

Variola 

Smallpox, one of the most venerable diseases, is an acute 
epidemic fever, with a high degree of infectivity, and an eruption 
that quickly passes through the stages of macules, papules, 
vesicles, and pustules. In all likelihood it has had more of an 
effect upon the history of the ancient and mediaeval world than 
any other similar sickness. 

2e 



418 THE MEDICAL DISEASES OF CHILDHOOD 

Causes. — The works of Klein and Hart have done much to fix 
the responsibility of the disease upon a specific bacillus. But 
since the investigations are as yet incomplete, we may at any rate 
conclude on the grounds of analogy that the active cause of small- 
pox is a micro-organism that finds its way into the economy 
through the mucous membranes of the nose, mouth, throat, lungs, 
and possibly stomach. The contagion is carried by the air, in 
contaminated articles, such as furniture, clothing, rags, books, 
and domestic utensils, from the patient during life or after death, 
from faeces, or by a healthy person who has been in communication 
with the contaminated person or things. The virulence of this in- 
fection is strongly marked, but most so during the stages of the 
vesicles and pustules, and the formation of crusts ; however, the 
virulence of the poison is not so important a factor in the spread 
of smallpox as is the susceptibility of the prospective patient. A 
virulent degree of infection may be followed by a light attack, 
while a mild degree may give rise to a severe, protracted, or fatal 
sickness. The personal equation is after all the deciding con- 
sideration, and even in the very young ages it has an important 
influence. While from certain tables of statistics one would draw 
the conclusion that older children and youths are the greatest 
sufferers from this disease, nevertheless no age, not even the 
unborn child, is free from danger. The main fact is that infants 
and young children are less exposed, and therefore seem to be less 
often attacked. In similar ways one may get the impression that 
males are more susceptible than females ; but here again the ques- 
tion of exposure is a weighty one, and in all probability may be 
sufficiently so to bring about this apparent conclusion. 

Symptoms. — From the time of exposure to that of invasion is 
a variable period of from one to three weeks. Exceptional cases of 
still greater extremes have been reported, but are so rare as to have 
no practical importance. Even these limits are greater than the 
large majority of cases possess, for usually incubation takes from 
ten to twelve days. At the end of this time the characteristic signs 
of the disease begin to show themselves. The child complains of 
headache and backache, the latter being especially severe. The 
pain is located in the small of the back, may radiate into the legs, 
and generally continues until or after the eruption appears. The 
general impression which the child makes is one of being 
thoroughly prostrated and seriously sick. The tongue is covered 



THE SPECIFIC INFECTIOUS DISEASES 419 

with a grayish fur. the breath is offensive, and nausea, vomiting, 
and epigastric pain are apt to be pronounced. Constipation is 
much more common in children than diarrhoea, and chills followed 
by convulsions are more often seen than in adults. Other ner- 
vous symptoms, such as drowsiness which may develop into coma, 
restlessness, lack of muscular control, teeth grinding, and delirium, 
are often seen. The temperature from the beginning of the 
symptoms mounts rapidly until within a few hours it may 
reach 40° C. (104° F.), and then may rise still higher. During 
these first symptoms, which last for two or three days, the throat 
shows nothing abnormal except an enlargement of the tonsils. 

A noteworthy part of the preliminary symptoms is the appear- 
ance of the so-called initial rash. It may come out during the 
first few days of the disease, and remain for a variable time up to 
four or five days. Its usual location is on the body and extrem- 
ities, rather than the face, and marks the places where the true 
eruption does not appear, especially in copious' amounts. The 
space that it covers is variable, so that no rule concerning this 
detail can be formulated. In character it may be erythematous, 
hemorrhagic, or a combination of both. The erythematous variety 
may resemble the rash of scarlet fever, of measles, or of erysipelas. 
The resemblance is general, for the color is apt to be less bright, 
it fades on pressure, leaves no stain, does not show the same local 
predilections, and is not accompanied by catarrhal symptoms. The 
haemorrhagic variety usually appears on the body daring the first 
three or four days, and for the most part is confined to the lower 
part of the torso. It may be light or dark in color, petechial in 
form, and in heavy crops may by convalescence produce large con- 
fluent spots. The light-colored rash disappears on pressure, while 
the dark does not entirely fade. In many cases the rash is a com- 
bination of erythema and petechia?, so that neither term may be 
used exclusivelv to designate it. A sub-varietv. seen in children 
rather than in adults, is the so-called purpuric rash, which receives 
the name from its close resemblance to ordinary purpura. It is 
dark in color, fairly circular in form, and irregular in distribution. 

Within a short time, usually one, two, or three days, after the 
outbreak of the first signs, the ordinary eruption of smallpox 
makes its appearance. Its primary location is on the face, scalp, 
hands, and arms, then on the rest of the body. The enanthem 
breaks out at the same time on the mucous membrane of the 



420 THE MEDICAL DISEASES OF CHILDHOOD 

mouth and throat, and in a few rare cases on the conjunctivae, 
vagina, vulva, and rectum. Usually two or three days are required 
before the external eruption is fully out ; it may be of use to call 
attention to its tendency to appear most luxuriantly on the parts 
most affected by pressure or friction from clothes. Its character 
and conformation in different children may vary considerably, and 
these different forms have been called discrete, confluent, and 
haemorrhagic eruptions. 

Its first appearance is in the form of small red spots which fade 
on pressure. They rapidly grow in size and hardness until they 
are distinctly papular. During the next day they increase still 
further in size, and show at the summit a metamorphosis into 
vesicles ; this change in the course of four or five days converts 
the whole papule into a vesicle which is about 0.5 cm. (i to \ 
inch) in diameter, dirty white or pearl-gray in color, multilocular, 
translucent, filled with serum, often pitted in the centre, and sur- 
rounded by a small reddish areola. At about the sixth day, the 
vesicle begins to change to a pustule. The umbilication begins 
to disappear, and its place is taken in almost all the vesicles by a 
small, dull-looking spot which gradually spreads out in all direc- 
tions. At the same time the areola increases in size and bright- 
ness, the vesicles grow in extent and height, and within two, three, 
or four days have become a pustule. This formation persists for 
about a day, when it spontaneously breaks. The liberated pus 
and serum dry, and form an offensive yellow or greenish yellow 
crust. After the lapse of a few days the crusts fall off, leaving 
the new, tender covering which gradually becomes like the rest of 
the skin surface. Where the ulceration has descended deeply into 
the skin, a permanent depression or pitting may remain ; but in 
most cases where proper care is exercised the process does not 
extend so far. In fact in some cases the pustule never breaks at 
all, but dries up and then is shed, leaving a clean, fresh surface. 

As the exanthem appears and develops, the enanthem keeps an 
an equal pace. From the beginning, however, its changes are not 
so radical and startling. It starts in the form of minute red 
spots which slowly enlarge somewhat, but never reach the size 
or elevation of the spots upon the skin. Simultaneously the 
mucous membrane becomes swollen and congested, so that at 
times it is not easy to make out all the characters of the erup- 
tion upon it. Here and there one can see an areola about a 



THE SPECIFIC INFECTIOUS DISEASES 421 

somewhat flattened papule, whose apex has a whitish hue. As 
the exanthem becomes pustular, the papules in the mouth and 
throat break down, leaving in its place a small ulcer. Juxtaposition 
may cause several of the ulcers to coalesce, thus producing a sup- 
purating area that is more or less thickly covered with necrotic 
tissue, pus, mucus, and bacteria. 

Such is a description of the discrete eruption. In the confluent 
rash the vesicles are close together, and the intervening space is 
covered by an erythema, so that the affected area, whether large 
or small, is entirely covered by the outbreak. The essential 
elements of the main type are, however, present. In hemorrhagic 
smallpox there are subcutaneous or cutaneous hemorrhages with 
or without the ordinary features of a variolous eruption. This 
variety when well marked is sometimes called black smallpox. 
It is often accompanied by haemorrhages from the mucous mem- 
branes and kidneys. A sub-variety, called peri- and sub-vesicular, 
is occasionally seen in which the vesicles, whether the eruption is 
discrete or confluent, become injected with a dull purplish color, 
while the areola is of a garnet rather than a red hue. 

The other symptoms have a close connection with the character 
and development of the eruption. The high temperature, which 
with pains in the head and back accompanies the initial symptoms, 
abates as soon as the eruption develops. In the course of a few 
hours, or a day or two, the fever largely or wholly disappears until 
pus begins to form in the vesicles, when it mounts to about 39.5° 
or 40° C. (103.3° or 104° F.> The degree of fever depends upon 
the comparative severity of the disease and the amount of pus. 
As the case progresses toward recovery the temperature gradually 
falls, the morning remissions becoming more marked, while the 
evening exacerbations mount less and less high. In very mild 
cases the fever may never run very high, but in severe attacks, 
especially in confluent smallpox, it may in the pustular stage 
reach 41.5° C. (106.7° F.), or higher. The respiration and pulse 
follow the temperature fairly well, except during unusual pus 
production, when the pulse-rate becomes very rapid, and its char- 
acter at times is weak and irregular. 

One of the most painful and troublesome features of smallpox 
is the oedema and swelling of the body surface, especially where 
the eruption is located, during the pustular and the second half 
of the vesicular stages. This swelling is irregular, so that the 



422 THE MEDICAL DISEASES OF CHILDHOOD 

contour of the face, neck, and even the body is quite changed. 
The eyelids are puffed out so that they are beyond control, the 
nose is huge, the ears large, thick, and bent forward, the lips are 
strangely out of their regular shape, project, cannot coapt, nor 
restrain the flow of saliva. The whole body surface is excessively 
irritable, sensitive, and painful, so that the ordinary friction of the 
bedclothes and necessary manipulations are hard to endure. 
Thus one finds much difficulty in keeping the eyes, mouth, ears, 
and body clean, so that there is additional discomfort as well as 
danger of any complicating condition which may be brought about 
by septic or irritating accumulations and deposits. Salivation, 
dryness of the throat, and laryngeal congestion may be particularly 
troublesome, although in most cases not dangerous. The main 
disorder of the gastro-intestinal track is constipation, which is not 
necessarily serious. The kidneys in ordinary cases may be in 
a state of acute degeneration, while in serious attacks there may 
be a distinct exudative nephritis. The inflammation of the skin 
may be of various degrees, and on account of the abscesses may 
leave an opening for the production of more extensive ulceration, 
erysipelas, and cellulitis. The nervous symptoms of irritability, 
delirium, convulsions, and mania vary according to the patient's 
weakness and sepsis. Partial or total paralyses of the face, neck, 
or extremities sometimes occur, but usually are not permanent. 

Treatment. — The prophylaxis is plainly of fundamental impor- 
tance. This is to a certain extent simplified in most houses because 
the patient as soon as a diagnosis is made is taken to a special hos- 
pital whose situation renders the spread of the disease almost impos- 
sible. Smallpox cases should not be treated in a city, but should 
always be removed to some remote locality. The necessity for 
this is very plain, since the virulence of the poison is such that 
aerial contamination is possible for the residents within a radius of 
three-quarters of a mile. When a patient has been removed, his 
apartment and every article of clothing, furniture, or domestic use 
must be disinfected by washing, boiling, or steaming, according to 
the nature of the thing cleansed. 

The medical treatment at present does not include the use of a 
specific. Doubtless there will be in the near future an anti-toxine ; 
but now we restrict our efforts to symptomatic and hygienic meas- 
ures. The patient must be confined to bed, the diet restricted to 
fluids, and the gastro-intestinal track emptied by means of small and 



THE SPECIFIC INFECTIOUS DISEASES 423 

repeated doses of calomel followed by a saline. The eyes should 
be thoroughly washed as often as may be necessary, and if the lids 
swell very much they may be treated with ice cloths. The nose 
and mouth must be thoroughly and frequently irrigated, and 
the whole body may be washed daily once or more times for 
the double purpose of cleanliness and the regulation of fever. 
The importance of keeping the skin as clean as possible in all 
stages is unquestionably great. Not only is the patient made 
more comfortable, but also the likelihood of extensive abscess 
formation with the resulting disfigurement of deep pitting is les- 
sened. As soon as pus begins to form, the continuous use of 
moist dressings (bichloride of mercury in weak solutions) will 
give considerable relief, and hold in check the septic element of 
the skin lesions. 

As far as drugs are concerned, little need be done. One of the 
principal indications is the relief of pain. In almost all cases the 
most direct method for this purpose is the use of opium in sufficient 
doses to keep the patient quiet. In young infants or in older chil- 
dren for whom opium may not be employed, the bromide of soda, 
with or without a small quantity of chloral, may be used. An 
additional need of treatment is the cardiac and general weakness 
which is apt to occur about the middle or end of the sickness. To 
combat this we may use alcoholic stimulation and also fairly large 
doses of strychnine. The complications should be treated accord- 
ing to their various indications. 

Prognosis. — The outlook depends upon the patient's vitality, 
age, and the question of previous vaccination. The younger the 
child, the greater the mortality. Children under four years of age 
seem to be only half as resistant to the disease as those of twelve 
or thirteen, and the difference in the death-rate between vaccinated 
and unvaccinated children is about as one is to ten. The differ- 
ence in sex seems to have a very slight bearing on the question, 
since statistics covering large numbers of cases show a greater 
mortality in males of about one per cent. The difference between 
discrete cases and confluent or hemorrhagic cases is, in regard to 
mortality, very great. In the former the prognosis is good, but in 
the latter the question of recovery is always a serious one. The 
degree of gravity seems to be in direct ratio to the amount of con- 
fluence or hemorrhagic involvement. 

The presence of serious complications, such as organic disease 



424 THE MEDICAL DISEASES OF CHILDHOOD 

of the lungs, kidneys, heart, or nervous system, provides an addi- 
tional element of danger, the exact importance of which varies with 
individual cases. 

Differential Diagnosis. — Smallpox is so rarely seen now, at least 
by the general practitioner, that delay in making a diagnosis, most 
of all in the initial stage, is very apt to occur. The main facts to 
be kept in mind are the presence of marked pains in the back, head, 
and epigastrium, chills, nausea and vomiting, high temperature-, 
respiration-, and pulse-rate, prostration, and the appearance from 
the first to the third day of an erythematous or petechial eruption 
or both on the abdomen, while no enanthem may as yet be seen. 
If after the lapse of the usual time, as stated before, a macular 
eruption appears on the face and scalp, accompanied by the 
formation of smaller macules on the mucous membrane of the 
mouth and throat, the conclusion that the case is variolous is 
almost certain. The contrasting points between this sickness 
and the other exanthemata may be seen in the table facing this 
page. 

Vaccinia and Varioloid 
vaccinia 

The practice of vaccination produces a local eruption of a 
papule, Avhich changes into a vesicle, and then into a pustule. 
Commonly there are some general symptoms of adenitis, fever, 
and malaise. To induce this protective disease we use a lymph 
obtained at the present time from inoculated calves. The former 
method of employing humanized virus, the so-called arm-to-arm 
method, has wisely been done away with on account of the pos- 
sible danger of a simultaneous communication of syphilis, tuber- 
culosis, erysipelas, cellulitis, septicaemia, and other suppurative 
processes. With this objection out of the way, there is very little 
danger left. It is held that absolutely sterile lymph is never 
found. Over against this we may set the fact that the micro- 
organisms which are regularly found, Staphylococcus albus epider- 
midis, S. pyogenes aureus, and S. cereus flavus, are not, unless 
present in relatively large quantities, necessarily dangerous ; and 
we have the additional fact that even these organisms we can 
remove from the fluid. 



: Symptoms. 



Ca' 



fi,much depres- 1 T 
)ated ; peeling prop 
g "strawberry" erup 
rat lire always Whi 
to 106°. Pulse lar j 
monly out of tiva? 
ver. Enlarge- com} 
ids proportion- , moo, 
sction. 



erally marked, 
atiou. Tongue 
r no appetite, 
ually 100° or 
erally acceler- 
tofeyer; often 
.... Glandular 
narkedly early, 
o glands about 



Re 

patcl 
tarrl- 
Mucl 
phot 

ehiti 
broi 
conn 
freqr 



pssion. Tongue 

irred: appetite 

Temperature 

Pulse little 

rated in pro- 

r. . . . Lymph 

enlarged ; ten- 

pcluding post- 

and inguinal. 



Re 
diffuj 

suffu 

eyes 

chitis 

pneu 
diarr 



in in head and 
ase when erup- 
Idema of body 


Mij 

of m 
eyes 
tion 
throa 


conjunctivitis, 

lgitis, and ade- 


mJ 

of ey 
ritate 













Length 
Disease. 


Eruption : 
Character. 


Eruption : Location. 


Eruption: Enanthem. 


Desquamation. 


Characteristic Symptoms. 


CATARRHAL SYMPTOMS. 




| 




Period. 


s™"™"" 


Complications. 


Convalescence. 


Scarlatina 
(Scarlet 
fever). 


Usually from 
2 days to 4 days. 


Brief: a few 
hours, rarely as 
long as 5 days, 
and very rarely 
7 days. Vom- 
iting frequent. 


About 1 
month. 


Dusky or light 
red, and often 
diffuse. Con- 
sists of many 
red points, 
which go to 

uake up a 
blush. 


Chest and neck, 
whence it spreads 
to rest of body. 


Appears £ to 1 day before 
exanthem. Small points on 
pillars of fauces, thence covers 
mouth with a scarlet blush. 
Thus strawberry tongue results; 
this continues into second week 
of disease. 


Generally copious; 
in shreds ; may be 
protracted. 


With much rash, much depres 
sion. Tongue coated ; peeling 
on 4th day. leaving "strawberry' 
tongue. Temperature always 
raised, often lo.")' to 100°. Pulse 
accelerated, commonly out ot 
proportion to fever. Enlarge- 
ment of neck glands proportion- 
ate to faucial affection. 


Throat affection 
proportionate to skii 
eruption. Dusky red 
White plugs in tonsil 

tivse unaffected. Lung 

moii, diarrhoea absent 


3 Albuminuria fre- Often pro- 
quent; also adenitis longed, ow- 
and otitis. Inflamma- ing to com- 
t ions of the throat plications, 
common. Sometimes 
arthritis. 


Morbilli 
(Measles). 


5 to 14 days, 
usually 10. 


3 to 4 days, gen- 
erally marked. 


About 1 
week. 


4th day. Pap- 
ular, brick-red, 
or darker and 
crescentic ; ap- 
pears thickly 
about the 
mouth and 
forehead. 


At first on fore- 
head and behind 
the ears ; thence to 
rest of face, and 
finally to the body 
and extremities. 


Koplik's spots sometimes as 
early as 3 days before exanthem. 
. . . Purplish or bluish papules, 
sometimes arranged crescentic- 
ally, on soft palate 1£ to 2 
days before exanthem. Thence 
spreads to cheeks. May last 
three to four days. Accom- 
panied by blue tongue. 


Seldom copious ; 
fine; continues for 
a few days, two 
weeks at most. 


Depression generally marked, 
often much prostration. Tongue 
furred; little or no appetite. 
Temperature usually loo" or 
more, pulse generally acceler- 
ated in proportion lo fever; often 
weak and dicrotic. . . . Glandular 
enlargement not markedly early. 
Usually limited to glands about 
angle of jaw. 


Redness of throat, 
patchy at first. Ca- 
tarrhal conjunctivitis. 
Much lachrymation and 
photophobia. Bron- 
chitis usually marked; 
broncho-pneumonia 
common. Diarrhoea 
frequent. 


Albuminuria very Commonly 
rare. fairly pro- 
tracted. 


Varicella 
(Chicken- 
pox). 


11 to 17 days, 
usually about 2 
weeks. 


Short and 
slight, in many 
cases none. 


J to 2 
weeks. 


1st or 2nd 
day, commonly 
is the first 
symptom; rosy 
red dots. First 
or early about 
nose. 


About mouth, 
chest, back, and 
arms, whence it 
spreads to face, 
scalp, and legs. 


Same time as exanthem. 
Small rose-red macules on 
uvula, velum palati, up to hard 
palate. Sometimes arranged 
crescentically. Fades in one 
day. 


May be copious; 
always fine. 


Little or no depression. Tongue 
clean or slightly furred ; appei ite 
often retained. Temperature 
may be normal. Pulse little 
altered, or accelerated in pro- 
portion to fever. . . . Lymph 
glands generally enlarged ; len- 
der and hard; including post- 
cervical, axillary, and inguinal. 


Redness of throat 
diffuse. Conjunctiva' 
suffused ; watering of 
eyes slight. Bron- 
chitis slight ; broncho- 
pneumonia rare. No 
diarrhoea. 


Albuminuria rare 
and slight. 


Rapid. 


Variola 
(Smallpox) 


Extremes, 5 
days to 3 weeks, 
usually 10, 11, 
12, or 13 days. 


2 or 3 days; 
consist of pros- 
tration, with 
pain in head 
and back. 


About 2 
weeks. 


Successive 
stages of ma- 
cules, papules, 
vesicles, and 
pustules, gener- 
ally preceded 
by the so-called 
initial eruption 


Face, scalp, and 
arms rather than 
body and legs. 


Appears simultaneously with 
exanthem; located on mucous 
membrane of mouth, throat, 
eyes, vagina, and rectum. Con- 
sists of minute red spots. 


None, except the 
falling off of crusts 
and scabs. 


Prostration, pain in head and 
back ; these decrease when erup- 
tion appears. CHdema of body 
surface. 


MUCOUS membranes 
of mouth, throat, and 

eyes inflamed ; saliva- 
tion or dryness of 
throat. 


Kidneys frequently, 
mi nni often severely, 
ilTeeted. Pyogenicaf- 

fections of ' the skin. 

Partial and tempo- 

'ai'Y paralysis of tare 

sometimes occurs. 


Varies j of- 
ten slow. 


Rubella, 
German 
Measles, 
o r Itoth- 
eln. 


1 to 3 weeks. 


Slight; may 
be fever and 
some post-cer- 
vical adenitis. 


About 1 
week. 


Rose-red ma- 
culo-papules 
not profuse. 


Face, forehead, 
and behind ears; 
occasionally ap- 
pears on body. 
More or lessor bodj 
may finally be 
covered with a fine 
blush. 


Few red spots on pharynx ; 
not always seen ; synchronous 
with exanthem. 


Slight and fine, or 


Moderate f ever jconjunctivitis, 

bronchitis, pharyngitis, and ade- 
nitis. 


Mucous membranes 

if eyes and throat ir- 
ritated. 


Practically none. 


tapid. 



THE SPECIFIC INFECTIOUS DISEASES 425 

With all extraneous infections eliminated, the result in the 
vast majority of cases ought to be productive of very little incon- 
venience or sickness, especially if the patient is properly prepared, 
and is in a fit condition to receive the inoculation. In the first 
place the child should be in fairly good health; unless there is 
immediate danger of infection new-born children should not be 
vaccinated, and the operation should be delayed until the patient 
has shown his ability to live and thrive. When this matter is 
settled, the part that is to receive the inoculation, usually the 
outer aspect of the left calf or upper part of the left arm, should 
be prepared as if for an operation. The skin should be thoroughly 
scrubbed with hot water and soap, then washed with alcohol, with 
corrosive sublimate solution, and finally rinsed with sterile water. 
There are various ways of accomplishing the vaccination : a space 
about three-quarters of a cm. square is scarified until the blood 
flows, or is covered at fairly wide intervals by a few lines which 
intersect at right angles. The dried vaccine is then moistened 
and thoroughly rubbed into the wound ; the liquid vaccine which 
is now put up in sealed capillary tubes is a distinct improvement 
over the quills and ivory points, since it is incapable of becom- 
ing contaminated by adventitious influence. Another method of 
using the liquid virus is to put a drop of it on the selected 
spot and then with a sterile needle or knife to scarify through 
the lymph. Still another method, and one that has given me 
much satisfaction, is to scrape off the upper skin with a scalpel 
until one produces a fine serous oozing on the denuded surface. 
The virus is then applied and allowed to dry. I have used 
this last method in many hundred cases, and I feel safe in 
heartily recommending it. One should try in a general way at 
least to regulate the amount of lymph to the age and weight of 
the child. 

The general practice of leaving the wound uncovered, or at 
best protected by some sort of wire shield is not, I believe, a good 
one. Here again the general principles of surgeiy should guide 
us. No one would think of leaving any other kind of wound 
quite unprotected, unless of course he were perfectly willing to 
invite infection. For the same reason a vaccination wound should 
be covered with an aseptic dressing held in place by a roller band- 
age. The result will be a very much smaller number of serious, 
or at least troublesome, inflammations and deep abscesses. The 



m 



426 THE MEDICAL DISEASES OF CHILDHOOD 

course of this disorder will in most cases be uneventful, there will 
be comparatively little fever, prostration, and adenitis. The band- 
age may be allowed to remain for seven or eight days, when the 
wound should be inspected. 

Usually the first four days pass uneventfully. Then one 
or more papules appear which quickly change into vesicles 
surrounded by a light areola. The vesicle steadily increases 
in size, and the contained lymph gradually becomes turbid. 
As the growth nears completion the summit becomes foveated 
and progressively dessicated; about the eleventh, twelfth, or 
thirteenth day the vesicle dries up or ruptures, leaving a 
crust of variable thickness. Within a short time this scab 
should fall off, and nothing but a reddish or purplish scar 
remains. 

When the symptoms and course of the disease are markedly 
severer, the cause resides in extraneous infection. This does not 
refer to variations in the development of the pock, such as super- 
numerary and confluent vesicles, or hemorrhagic development, or 
keloid, or the appearance of a harmless urticarial or erythematous 
rash. These are unforeseen variations, and cannot be guarded 
against. But such complications as noteworthy suppuration, gan- 
grene, auto-inoculations, the serious skin and systemic diseases, 
should not occur. Likewise one cannot foresee or prevent the 
few rare cases of delayed incubation. In this as well as in other 
problems of the subject are involved the elements of age, idiosyn- 
crasy, season, and strength of vaccine. A weak virus may lead 
the physician to believe that the child is not susceptible or 
only faintly so, or two weeks or more may elapse before the 
vaccination "takes." Almost everybody has noticed that a 
pock develops more quickly in warm than in cold weather. 
The question of susceptibility is hard to understand; occa- 
sionally one meets a child who seems proof against successive 
attempts, although success is almost bound to come if the in- 
oculations are repeated often enough. Equally inexplicable are 
such susceptible cases as the remarkable one of Allbutt, where 
there were three successful vaccinations, each one of which 
was followed within a comparatively short time by an attack of 
variola. 

The treatment of the various conditions that call for attention 
should be conducted upon surgical principles. 



THE SPECIFIC INFECTIOUS DISEASES 



427 



VARIOLOID 



The practice of vaccination is so widespread that some cases 
of variolous infection which run a modified course must naturally 
be seen. The disease is then of a mild type, so much so at times 
that a mistake in diagnosis is readily excused. The same phe- 



PUL. 


?ESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


170 


70 


FAH. 
308 


SEN. 

42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


41.1 
































140 


55 


105 


40.5 
































130 


50 


104 


40.0 
































120 


45 


103 


39.4 
































110 


40 


102 


38.8 




i 


\ K 


,'\ 
























100 


35 


101 


38.3 


; 


f j 


\j\ 


\ 

i 


I 

fc 


A 


A 


















90 


30 


100 


37.7 








Y«/ 


AV 




I 

\ 
\ 


















80 


25 


99 


37.2 


' i 1 
1 1 
1 1 














AT 


Y- 




/ 










70 


20 


98.6 


37.0 
















\ 


x 














68 


36.6 
















V 


' \ 


' \ 


. 










60 


15 


97 


36.1 







































































PULSE, RESPIRATION AND TEMPERATURE CHART OF VARIOLOID. 
AGE, 4 YEARS. 
PULSE. _______ RESPIRATION TEMPERATURE 



Fig. 80. 



nomena may be seen in a patient who has had variola or who 
for some puzzling reason is only partially susceptible to the 
poison. 

Usually the disease begins like a mild variola, but the regular 
course is not followed : the attack may suddenly wither away, or 
the development of the eruption ceases before pustulation sets in, 



428 THE MEDICAL DISEASES OF CHILDHOOD 

or there are very few and scattered pocks. The initial symptoms 
are short, and the papules may change into vesicles within a few 
hours or a day. The appearance of the eruption is not quite like 
that of variola : the papules and vesicles are smaller, more irregu- 
lar in form and outline, less likely to have a well-marked areola. 
After two, three, or four days many vesicles dry up, and only a 
few develop into pustules. These latter are short-lived, reach 
their maturity within a day or two, and they break open or dry up. 
Finally there may be a slight desquamation about the new epider- 
mis. The general symptoms are likewise abortive or mild. The 
temperature is moderate or scarcely above normal, there is little 
pain, tenderness, or swelling, and the nervous symptoms are 
mild. 

The complications are rare, and if any occur they are generally 
the result of infection of the surface wounds. 

The treatment is purely general and symptomatic. The im- 
portant precaution of isolation must be kept in mind, no matter 
how trivial the attack may be ; for a trifling case in one person 
may be the starting-point for a violent variola in another. Pro- 
phylaxis, isolation, and disinfection should be as rigorous as in an 
ordinary case of smallpox. 

Diphtheria 

Within the last few years our ideas concerning this disease 
have changed so radically that at one stroke all our statistics of 
mortality as well as methods of treatment have become antiquated 
and useless. Diphtheria, instead of being a frightful scourge, the 
very name of which made parents tremble, may now be looked 
upon as a curable disease in most children who receive reasonably 
good care. 

Cause. — The discovery of the specific germ by Klebs in 1883, 
and its isolation and description by Loeffler in 1884, have dwarfed 
every other element of aetiology into total insignificance. Thus 
we are assured that this bacillus, when once lodged on a surface, 
usually mucous, which is in a fit condition of asthenia or irritation, 
will develop in its characteristic fashion, will give rise to the for- 
mation of a false membrane in the locality in question, and the 
elaboration of soluble toxins and tox-albumins throughout the 
whole body. These latter elements are the really serious factors 
of the disease, and should receive the greatest part of our atten- 



THE SPECIFIC INFECTIOUS DISEASES 



429 



tion when we attempt to treat it. In the diffusion of the infec- 
tion the bacillus itself is the responsible agent, aud to exclude it 
is to stamp out the dangers of diphtheria. This is no easy matter 
on account of the tenacity with which this micro-organism resists 
extinction. But in addition to this we commonly find, especially 
in severe cases, one or more other forms of bacterial life, usually 
streptococci and staphylococci. These may complicate the spe- 
cific condition to such an extent that the strict idea of diphtheria 
no longer holds good, and we should then speak and think of a 
mixed infection of various degrees of complexity and severity. 




Fig. 81. — Diphtheritic Inflammation of Pharynx, x 25. 

Lesions. — The parts which most strikingly attract attention 
are such as are covered wholly or in part with the local inflamma- 
tion and membrane. These are the tonsils, pharynx, uvula and 
soft palate, nose, larynx, trachea, and bronchi ; in addition the 
process may, in rare cases, extend through the lungs, into the 
oesophagus, stomach, and intestines, may invade the conjunctivas, 
the ears, the vulva, glans penis, anus, and recent wounds. In the 
more remote situations, such as the eyes and genitals, the mem- 
brane in all likelihood is caused by tactual infection as often as 
by anatomical extension. In similar ways fresh wounds, such 



430 THE MEDICAL DISEASES OF CHILDHOOD 

as tracheotomy wounds, may become the seat of local inflamma- 
tion. The farther away from the mouth and nose, the rarer is the 
spread of the diphtheritic membrane. In this structure the Klebs- 
Loeffler bacillus is found in great abundance ; in some cases, usu- 
ally those of great virulence, it may be encountered in the spleen, 
in the blood, in leucocytes, possibly in other organs. 

When the mucous membrane is attacked, it falls into a state of 
catarrhal inflammation and the epithelium degenerates. In some 
rare cases the process seems to stop here ; but in the majority the 
degenerated epithelial layer disappears, and its place is taken by 




Fig. 82. — Diphtheritic Inflammation of Trachea. X 25. 

a meshed stratum of fibrin which holds epithelial debris, pus-cells, 
blood-cells, cocci, and the diphtheria bacillus. The membrane 
grows from its under surface, or the mucous membrane, up ; and 
therefore, near this mucous membrane, the Klebs-Loeffler is most 
commonly found, sometimes in almost pure cultures, while in the 
upper layers one generally finds the various kinds of streptococci 
and staphylococci that readily find access to the mouth. The 
diphtheria bacillus usually, on disappearing, leaves no permanent 
marks of its invasion ; in some cases, however, more or less exten- 
sive ulceration or necrosis occurs, which may be attributed to 



THE SPECIFIC INFECTIOUS DISEASES 



431 



the other pyogenic cocci, that constitute the ordinary mixed 
infection. 

Outside of this local process, changes of considerable impor- 
tance occur in other parts of the body, such as the cervical, bron- 
chial, and mesenteric glands, which become swollen, softened, and 
possibly broken down ; in the kidneys, which are cloudj-, anaemic, 
degenerated, and acutely inflamed ; in the liver, which shows areas 
of cell-necrosis and sub-capsular haemorrhage ; in the heart muscle, 
which often has areas of fatty degeneration ; in the spleen, which 
is swollen, congested, and degenerated ; in the lungs, which show 




Fig. 83. — Lymphadenitis of Diphtheria. X 80. 

the signs of a bronchitis or a profuse growth of the diphtheria 
bacillus with vaiying amounts of membrane and a resulting true 
diphtheria pneumonitis; or on account of the presence of the pneu- 
mococcus or varieties of streptococcus, a lobar pneumonia or 
broncho-pneumonia. In the blood there is a decrease of red 
blood-cells and haemoglobin, and in the severe cases an increased 
leucocytosis. One of the most constant and important changes 
is the parenchymatous degeneration that occurs in the peripheral 
nerves. The toxines of diphtheria seems most of all to affect 
nerve tissue, and thus, even in comparatively mild cases, we find 



432 THE MEDICAL DISEASES OF CHILDHOOD 

the white substance of the medullated fibres as well as the axis 
cylinder degenerated and broken down in irregular areas. So long 
as parts and branches of the affected nerves are left unharmed, 
the function is not entirely destroyed, and in ordinary cases the 
impression which is thus conveyed is one of asthenia rather than a 
degree of paralysis. 

Symptoms. — From the time when the child receives the infec- 
tion until the first symptoms appear is a period which may vary 
within wide limits. This has been known to constitute no more 
than half a day ; usually the symptoms manifest themselves before 
a week has elapsed ; in rare instances the first signs may be put off 
for two or even three weeks. The deciding factors seem to be the 
condition of the mucous membrane upon which the bacillus seeks to 
grow, and the vitality of the patient. A mucous membrane which 
is irritated or inflamed acts as a fertile culture-ground for this 
as well as other micro-organisms. On the other hand, a healthy 
mucous surface resists the attack so successfully that unless some 
form of irritation or degeneration supervenes, the triumph of the 
germ may be indefinitely postponed. The hypertrophic tissue of 
adenoid vegetations is a good resting or storage ground for this 
organism until some disorder of the surrounding or adjacent tissue 
lights up the disease, and permits it to pursue its course. 

Commonly, careful observation will discern prodromal symp- 
toms before membrane appears. There are moderate fever, a 
gradually increasing sense of physical depression, possibly a chill. 
There may be disorders of the digestive system, followed sooner or 
later by a sore throat. Rarely there may be no membrane at all, 
but the constitutional symptoms go on in the ordinary way. In 
the vast majority of cases, however, the faucial mucous membrane 
becomes swollen, reddish, and glistening. There may be disin- 
clination to swallow, and the glands at the angle of the jaw are 
swollen and tender. In some few cases the parotid gland is like- 
wise enlarged and sensitive, and often the whole neck may be 
sensitive. This is followed at an uncertain interval by the appear- 
ance of one or more small areas of membrane which, starting com- 
monly on the tonsils, uvula, or pharynx, grow or coalesce so that 
from hour to hour the increase in size may be noticed. The mem- 
brane varies in character in different cases : it is gray or dull 
white in color, only occasionally taking on a darker hue ; it may 
be thick or thin, closely or loosely adherent, tough or friable. 



THE SPECIFIC INFECTIOUS DISEASES 433 

The pure diphtheritic membrane is often thinner and less easily 
removed than that due to mixed infection, which also has the 
greater tendency to assume a dark and peculiarly unwholesome 
color. The unmixed infection has a mucous membrane which, 
when freed from its peculiar covering, is not badly abraded or 
torn, while the opposite is often the case in the so-called mixed 
infection. The last-named membrane more easily decomposes than 
the first, thus giving rise to the so-called putrid sore throat. In 
proportion to the severity of these inflammations there will be a 
swelling of the underlying parts, so that the usual relations are 
disturbed, and the characteristic form is temporarily destroyed. In 
rare cases of marked severity the cellular tissue of the neck may 
likewise be involved and very much swollen. On the other hand, 
the disease when found in the nose frequently has much less 
swelling of the tissues; there is a concomitant nasal discharge 
that is thin and sharp at first, gradually becoming puriform and 
blood-streaked. 

While these local phenomena are developing, the general 
symptoms progress with an equal step. Their seriousness varies 
not so much with the extent of the membrane as with the inten- 
sity of the intoxication, which is the principal factor in the disease. 
The younger the child, the harsher is the onset of the disease apt 
to be. The temperature is atypical, rarely exceeds 30.5°-40° C. 
(103.1°-10-4° F.) and in markedly asthenic cases may be sub- 
normal. The respiration is fairly rapid, excepting in laiyngeal 
and nasal cases, where it becomes rapid, strenuous, and labored. 
The pulse is quick, shallow, and sometimes irregular, most of all 
in severe attacks and with weak patients. The weak heart is one 
of the characteristics of diphtheria, and may exist in a noteworthy 
degree when muscular degeneration is not noticeably present in 
other parts of the body. The peculiar toxines have an especial 
affinity for the cardiac structure, and may bring about a fatal 
result, either by an acute myocarditis, or by a paralvsis of the par 
vagum; in rare cases the same result is obtained by cardiac 
thrombosis. 

The wearing effects of the sickness are regularly shown in an 
ansemia, whose tendency is rather in the way of excess than trivi- 
ality. The sense of prostration continues throughout the disease ; 
when the fever is high there may be marked restlessness and 
possibly delirium, while in the asthenic cases the child may be 

2f 



434 



THE MEDICAL DISEASES OF CHILDHOOD 



dull, stupid, or even comatose. After the disease has well begun, 
the kidneys fall under the action of the toxaemia, and the urine 
shows the presence of albumin and casts in varying amounts. 

In young children there is always an acute danger of an 
involvement of the larynx, to a greater extent than in those of 
more advanced age. This may occur as an extension of the 
pharyngeal membrane, or the disease may begin in the larynx, 



PUL. 


RESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


170 


70 


FAH. 
108 


CEN. 
42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


41.1 
































140 


65 


105 


40.5 










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N. 


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130 


50 


104 


40.0 




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V' 




N-" 


N. 

\ 
V 


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V 


120 


45 


103 


39.4 


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/ 
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V 


























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110 


40 


102 


38.8 


/ 

/ 




J 


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100 


35 


101 


38.3 


/ 


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V 


I 


J 






















90 


30 


100 


37.7 


/ 


V 




V 


V 




V* 


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80 


25 


99 


37.2 




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V 




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70 


20 


98.6 


37.0 


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N./ 


x -i 


























98 


36.6 
































60 


15 


97 


36.1 







































































PULSE, RESPIRATION AND TEMPERATURE CHART OF DIPHTHERIA. 
AGE, 5 YEARS. 

PULSE RESPIRATION^ ..__.._« 'TEMPERATURE 



Fig. 84. 



and thence spread up or down. In some cases there may be one 
or more patches in the throat, an area in the larynx, and between 
them a clear space. The laryngeal symptoms of hoarseness, diffi- 
cult breathing, and spasmodic cough are so characteristic that they 
cannot be mistaken. When the larynx is invaded, not only may 
the diphtheritic germ and membrane make their way into the 



THE SPECIFIC INFECTIOUS DISEASES 435 

trachea and lungs, but also there is imminent danger of the aspi- 
ration of other pathogenic germs, such as pneumococcus and 
streptococci, with the resulting development of various degrees 
of pneumonia and broncho-pneumonia. There is great danger of 
such complications when the larynx and throat have become 
partially paralyzed. 

Another extension of the disease involves the nose. This 
location may in a few cases be primary, but usually it is secondary 
to pharyngeal diphtheria. The nose is occluded, and the patient 
is forced to breathe through his mouth. Occasionally in the thin 
muco-purulent discharge there may be traces of blood. This 
condition, which is easily confused with rhinitis fibrinosa, is 
especially liable to persist for some considerable time, even when 
the membrane seems to have vanished. It is commonly capable 
of producing hypertrophy of the pharyngeal tonsil, in the recesses 
of which the bacillus lies concealed for weeks after the end of the 
disease. In other rare cases the membrane covers more or less of 
the buccal mucous membrane — the cheeks, tongue, gums, even 
the lips. Outside of the results occasioned by so great a spread 
of the disease and the consequent swelling and loss of local mus- 
cular control, this condition gives no especial symptoms. In some 
of these very rare cases the membrane may extend into the oesoph- 
agus, and thence into the stomach. The resulting inflammation is 
accompanied by such persistent vomiting that the outcome of the 
disease is seriously influenced. This, however, is not the only 
occasion for this symptom, which may occur as the result of the 
toxaemia, or the nephritis. 

One of the commonest and most dreaded effects of diphtheria 
is the paralysis that comes during or after the main course of the 
disease. Commonly it occurs during the second week, but it has 
been known to appear as early as the third day, or as late as two 
months after the main symptoms have vanished. Its commonest 
seat is in the fauces. It is manifested by a strange wooden tone 
of the voice and some degree of difficulty in swallowing. The 
degree of palsy varies in each case, and the accompanying s}^mp- 
toms of functional disability will demonstrate both the location and 
the extent of the lesion. In some places this complication immedi- 
ately becomes of the gravest importance ; thus, if the glottis is 
affected, the epiglottis and larynx cannot react to their usual 
stimuli ; as a result, particles of mucus, membrane, and food may 



436 THE MEDICAL DISEASES OF CHILDHOOD 

enter the lungs, and start a fatal septic pneumonitis. Any other 
part of the body may be likewise affected so that deformity of the 
trunk or extremities, or death from respiratory or cardiac paralysis, 
may occur. Lesions of the spinal cord are very rare in children. 

One ought to call attention to the possibility, which, by the 
way, is not common, of an arthritis, that is apt to involve the 
smaller joints. This complication is characteristic, I believe, of 
mixed infections, and should be regarded as a clear case of pysemic 
infection. 

Treatment. — Since the brilliant success of the diphtheria anti- 
toxine has been demonstrated, the former methods of treatment 
have been entirely overthrown. At the outbreak of the sickness 
the patient should immediately be isolated, and the remaining 
members of the family, especially the children, be injected with an 
immunizing dose (150 to 300 units, Behring standard, according 
to age) of the serum. The sick-room should be as remote from the 
other apartments as possible ; it should have as much air and 
light as the situation of the house permits, and must be stripped 
of its carpet, pictures, curtains, and all unnecessary furniture. 
Those who enter or attend on the sick-room must not mingle with 
the family, and every effort should be made to divorce the two 
establishments to the last detail. The routine practice of clearing 
the patient's gastro-intestinal track by small and repeated doses of 
calomel must not be omitted. Without delay the child should 
receive a full dose of the anti-toxic serum (from 1000 to 3000 
units, Behring standard) ; within a few hours the temperature will 
fall, the respiration become easy, the nervous symptoms and depres- 
sion markedly decrease, and the spread of the membrane be checked. 
If these results do not appear, the injection may be repeated on 
the following day. In some cases a discrete maculo-papular rash 
may appear about one week after the injection. Some prac- 
titioners have claimed that this is due to deficient purity of the 
serum. At all events, it is not dangerous, and requires no more 
than symptomatic treatment. 

Since cases of mixed infection are so common, we must be pre- 
pared to treat other bacteria besides the specific bacillus. Want- 
ing an efficient anti-streptococcus serum, our efforts are directed 
to keeping the nose and throat as clean as possible, by free irriga- 
tions of the former and sprayings of the latter. Saturated solutions 
of boric acid, with or without the admixture of peroxide of hydro- 



THE SPECIFIC INFECTIOUS DISEASES 437 

gen, are a useful means for the throat, as is likewise (for older 
children) a weak solution (1 : 10,000) of bichloride of mercury. For 
nasal irrigation one may employ warm normal saline solution, or 
Seller's solution. From the first it may be necessary to use stimu- 
lants, the best of which are alcohol and strychnine. The diet 
should be fluid, and administered in small and repeated amounts. 

Complications should receive the treatment which belongs to 
them. Laryngitis, when combated by the anti-toxine, rarely calls 
for tracheotomy, and not nearly so often as formerly for intuba- 
tion. After the fever and the local evidences of the disease have 
disappeared, the child should yet be kept in bed for from one to 
two weeks, to guard against the danger of heart failure due to 
exertion. After he has left the sick-room all its furniture, bedding, 
utensils, books, and toys should be most thoroughly disinfected or 
burnt. The paper should be taken from the walls, and the wood- 
work most thoroughly scrubbed and cleaned. After the room has 
been exposed to the air and sunlight for at least a week, it may 
again be occupied. 

Although the need of intubation is not as frequent as it for- 
merly was, nevertheless there are occasional cases where it must 
be practised, especially in infants. It is indicated where the 
laryngeal obstruction is marked; such obstruction may be due 
to diphtheritic laryngitis or to oedema of the larynx, resulting 
from mixed infection, burns, scalds, and wounds, especially when 
there is no great swelling of the fauces and tonsils. The instru- 
ments which we use are those devised by the late Dr. O'Dwyer of 
New York. The set consists of seven tubes, each of which has an 
obturator, an introducer, an extractor, a mouth-gag, and a scale 
with which to select the proper tube according to the age of each 
child. In the right shoulder of each tube is a small hole, through 
which a silk thread, designed to prevent the swallowing of the 
tube, may be passed. All the instruments before being used 
should be sterilized, and then placed in hot water in order to be 
properly warmed. 

The patient should be securely wrapped in a blanket, so that 
his arms, body, and legs may be comfortably and securely held. 
The nurse supports him on her lap, grasping his arms above the 
elbows with her two hands ; his head may be held rigid by another 
assistant, who simultaneously may keep the mouth-gag from slip- 
ping. The head, neck, and body of the child must be held in a 



438 THE MEDICAL DISEASES OF CHILDHOOD 

right line, and one must not allow the head to be strained back- 
ward and the throat to be contracted and protruded, as the patient 
in his struggles is bound to attempt. The introducer is then 
attached to the obturator in the tube, the thread passed through 
the aperture in the shoulder and held by the ringers of the oper- 
ator's right hand. The index finger of his left hand, after being 
protected by a few layers of gauze or rubber protective, is passed 
into the patient's throat until it touches the epiglottis. Using 
this finger as a guide, the operator passes the tube until its free 
end enters the larynx, when a slight pressure will place it in its 
proper position. While the obturator is being removed the tube 
may be kept in place by the guiding left finger. The operation is 
not a difficult one if the tube in passing through the mouth is kept 
in the median line, and is not allowed to rise in the throat above the 
base of the tongue. If the tube enters with difficulty, the cause is 
either that it is too large, or that a plug of mucus and membrane 
has been forced down in front of it. In either case no force should 
be used ; a smaller tube should then be substituted, or the child be 
allowed to expel the obstacle. As soon as the tube is properly 
located the child will cough more or less violently for a short time 
to clear the passage, and then should breathe with a reasonable 
amount of ease, while the cyanosis and other signs of respiratory 
obstruction should pass away. After the child has become quiet, 
the thread which secures the tube may be passed between two of 
the teeth or along the gums, out at the angle of the mouth, and 
secured around the ear or fastened to the cheek by a strip of 
adhesive plaster. If its presence in the mouth prove too uncom- 
fortable, relief may be obtained by passing it through the nares, 
and then making it fast to the cheek. Some children persist in 
pulling at the string as soon as they are freed from the blanket; 
but this is easily obviated by covering their hands with stockings, 
which are to be fastened above the wrists. 

If the tube, while it is in process of insertion, is not kept in the 
median line and sufficiently close to the root of the tongue, it is 
apt to pass into the pharynx or the oesophagus. The error is 
usually recognized without trouble, not only because the shoulders 
are not felt in their usual position, but also because the patient 
experiences no relief. Sometimes, but rarely, a mass of membrane 
may be pushed before the tube into the trachea ; in this case the 
respiratory obstruction increases, and if, after the tube is removed, 



THE SPECIFIC INFECTIOUS DISEASES 439 

the patient is unable to expel the mass, tracheotomy should be 
performed without delay. A very rare accident has been known 
to follow the use of too small a tube or the employment of too 
much force : here the shoulders of the tube slip within the false 
vocal cords instead of resting upon them. In such a contingency 
the instrument must be withdrawn, and replaced by one of a proper 
size, or greater gentleness must be observed. In the few cases 
where the tube has become freed from the thread and swallowed, 
it has been passed through the intestines without serious trouble. 

The feeding of these cases is always a matter of importance, on 
account of the danger of inspiring liquid food through the lumen 
of the tube. Some children soon acquire a remarkable proficiency 
in directing the food away from the partly inefficient epiglottis. 
In those patients who are less capable one may obtain safety by 
placing them, while feeding, on their backs, and allowing the head 
to hang lower than the chest. Older children who experience this 
trouble may be fed upon semi-solids, such as strained gruels, soft- 
boiled eggs, mush, and milk-toast. In both infants and older chil- 
dren the amount of fluids that usually would be swallowed may be 
decreased if enemata of water, each containing about thirty grammes 
(one ounce), are administered. In all cases the throat must be 
thoroughly sprayed after feeding, as well as in the intervals, with a 
mixture of peroxide of hydrogen and a saturated solution of boric 
acid. 

There is no fixed time at which the tube may be permanently 
dispensed with, but it may vary from two days to two weeks. 
Before the use of the diphtheria anti-toxine the longer periods were 
more frequently encountered than at present. As a rule, an attempt 
at dispensing with the instrument may be made at the end of two 
or three days ; if the child is yet unable to breathe with sufficient 
ease, the tube should be replaced, and allowed to remain for two 
days more. The operation of intubation need not be looked upon 
as an especially difficult one, but it demands skill and judgment 
on the part of the physician, and ceaseless vigilance on the part of 
the nurse. 

Prognosis. — The former opinions concerning the chances of 
life in diphtheria must be put aside. For we know quite certainly 
that in the ordinary pure infection which has been promptly treated 
with the anti-toxic serum the danger to life is comparatively little, 
nor are the nervous complications to be feared as much as in former 



410 THE MEDICAL DISEASES OF CHILDHOOD 

times. In the mixed forms of infection, most of all where there 
is a broncho -pneumonia due to the invasion of streptococci, the 
case becomes quite different, and a fatal outcome is not unusual. 
In institutions these latter cases have a mortality of fifty per cent 
or more ; but the experience of institutions is not that of a favorable 
class of private patients. All in all, one may say that diphtheria is 
dangerous in proportion to the youth of the patient, to the delay in 
recognizing the disease and administering the anti-toxine, and 
finally, to the presence of mixed infections, especially when such 
infections cause a broncho-pneumonia. In institutions, and accord- 
ing to municipal statistics, with the unfavorable class of patients, 
the mixed infections, and the many inevitable inaccuracies, the 
mortality has been lowered to about fourteen per cent or fifteen 
per cent. In private practice it should fall to one-half or one-third 
of these numbers. 

Differential Diagnosis. — The main sources of confusion are 
follicular tonsillitis and allied disorders of the mouth, the mem- 
branous sore throat of scarlet fever, and the mucous eruption of 
syphilis. The history, the surroundings, the occurrence of diph- 
theria in the house or neighborhood, and the presence of albumi- 
nuria will do much to clear up the diagnosis. Usually the difficulty 
is to distinguish between diphtheria and follicular tonsillitis : the 
former has a moderate fever, usually a gradual onset, and a mem- 
brane that has a tendency to spread and maintain its continuity. 
The latter has a high temperature, a sudden onset, and its mem- 
brane appears in isolated dots that later may coalesce. The supreme 
test, however, is the bacteriological examination, which may, in 
doubtful cases, need one or two repetitions. These doubtful cases 
should, until certain information is obtained, be regarded as diph- 
theria, and treated accordingly. 

Epidemic Infectious Parotitis 

Mumps is a somewhat uncommon specific epidemic disease, 
characterized by its high degree of infectivity, and a swelling of 
the parotid glands and the adjacent tissue. The micro-organism 
which causes it is, as yet, not positively known, although Michaels 
has recently described a small diplococcus which he believes to be 
the germ in question. It was taken from Steno's duct and a 
wound of the gland. Whatever the poison is, it is communicated 



THE SPECIFIC IXFECTIOUS DISEASES 441 

by direct contact or by indirect means, such as an otherwise 
unaffected person, by clothing, or furniture. Infants are rarely 
attacked, and most of our cases occur between three and a half 
years and the end of childhood. 

The process, it is believed, usually begins in the salivary ducts, 
which become congested, swollen, and more or less thoroughly 
occluded. The gland itself then partakes of the same inflamma- 
tion, which spreads and infiltrates the surrounding area. Some- 
times there are infiltration and oedema of the buccal and pharyngeal 
mucous membrane. 




Fig. 85. —Epidemic Infectious Parotitis (Mumps). X 80. 

Symptoms. — From the first sign of sickness, after an incuba- 
tion period of from two to three or three and a half weeks, the 
possibility of contagion exists, and is supposed to continue for 
upward of three weeks. The first signs are apt to consist of a 
slight amount of fever, restlessness and malaise, nausea, and ten- 
derness about the affected glands. This prodromal period lasts, 
roughly, for a clay or two, after which the hollow under the ear 
begins to fill out. The swelling continues to increase for three or 
four days, the circumjacent area is markedly enlarged, the sub- 
maxillary glands are also swollen, and the whole throat feels stiff 



442 THE MEDICAL DISEASES OF CHILDHOOD 

and sore. At this time the temperature may mount as high as 
40° C. (104° F.) ; the swelling extends from behind the ear well 
on to the face, so that the lobe of the ear marks the approximate 
centre of the enlarged area ; the pain and discomfort may be 
extreme, and the child looks worried and prostrated. The fever, 
if left to itself, would now subside ; but in most cases the gland 
on the opposite side begins to swell, and goes through the same 
course as the first. After the swelling has reached its height in 
the later or second gland, the temperature quickly returns to 
normal. As the contour of the face falls back into its natural 
lines the salivary secretion becomes smaller, and may even go so 
far as to leave the mouth in an exceedingly uncomfortably dry 
condition. After the lapse of a week and a half or two weeks the 
parts usually return to their normal shape. 

The order of occurrence of the swelling is not always the same. 
While it is true that in three-quarters of all the cases one gland 
closely follows the other, nevertheless one occasionally sees both 
sides simultaneously involved, or one side following the other at an 
interval of several days or weeks, or one side may alone be affected. 
Other unusual features are a complicating orchitis in older boys, in 
girls a swelling of the external genitals and breasts, enlargement 
of the inguinal glands, and a tenderness of the ovaries. Other rare 
complications are meningitis, meningo-encephalitis, and functional 
nervous disorders, deafness caused by disease of the middle ear or 
labyrinth, nephritis, functional disorders of the gastro-intestinal 
track, and adventitious suppuration of the affected parotid gland. 

Treatment. — From the first the child should be confined to 
bed, where he must remain until the temperature is normal. He 
should then stop indoors until three weeks from the beginning of 
the disease have elapsed. The gastro-intestinal track should be 
emptied by a saline cathartic, or small and repeated doses of calo- 
mel followed by a simple cathartic. The mouth and nose should 
be kept clean by frequent sprayings and douchings with an alka- 
line antiseptic solution, and the diet should be restricted to fluids. 
The patient should receive one or two lukewarm sponge baths 
daily, and the ventilation of the sick-room must be carefully pro- 
vided for. Very little treatment need be given to the enlarged 
glands. In ordinary cases they may be left alone ; but very large 
swellings give somewhat less pain if hot applications be prescribed 
for them. A pad of aseptic gauze, wrung out of a hot two per cent 



THE SPECIFIC INFECTIOUS DISEASES 443 

carbolic solution, and covered by gutta percha tissue, answers the 
purpose much better than the old-fashioned and unclean poultices. 

The complications, whatever they may be, are to receive their 
ordinary treatment. It is wise, during and after convalescence, to 
promote excretory action ; for this purpose one may use small doses 
of the citrate of magnesia or the compound mixture of rhubarb and 
soda. 

Differential Diagnosis. — The one point of confusion is the pos- 
sibility of mistaking mumps for an acute swelling of the lymph- 
glands of the neck. If one keeps in mind the history of contagion, 
the usual involvement of both sides, the locations of the swelling 
from behind the ear on to the face, the rapid rise and fall of the 
tumor accompanied by a similar movement of the fever, and on the 
other hand, the fact that swollen lymph-glands usually have a dis- 
coverable cause, it ought not in the large majority of cases to be 
difficult to get at the truth of the matter. 

Pertussis 

This disease is one of the most infectious disorders that attack 
children. It is characterized by respiratory spasm and the convul- 
sive cough that are exceedingly trying to the patient, and almost 
equally so to the relatives and attendants who are present. This 
is especially true of infants or very young children who form by far 
the greatest number of patients, for fully fifty per cent of all cases 
occur before the third year of life is passed. Most children by the 
time that they are ten years old have passed through the ordeal, 
and thus become reasonably well protected. Nevertheless, one 
occasionally meets the disease in youths, early manhood, and rarely 
in old age. 

Causes. — Many attempts have been made to decide upon the 
exact cause of whooping-cough. That it is due to the invasion of 
a micro-organism is certain, and Afanassief, Burger, Cohn, Neu- 
mann, and Koplik have done much to give us a good idea of what 
this germ is. While not absolutely certain, nevertheless one may 
reasonably believe it to be a streptococcus which is communicated 
through the expired breath and saliva. Thus the contagion is 
easily spread, especially as the patient is not necessarily confined 
to his room during the infective period. 

Lesions. — The pathological changes which pertussis entails 
are few and unimportant. All that one can find is a moderate de- 



444 THE MEDICAL DISEASES OF CHILDHOOD 

gree of congestion in the mucous membrane of the pharynx, larynx, 
trachea, and the larger bronchi. There is likewise a tendency to 
the production of acute degeneration in the kidneys, exaggerated 
in rare cases to an acute exudative nephritis. The stomach and in- 
testines very easily become congested, and are copiously bathed in 
a mucoid secretion. Any further changes that occur are the effect 
of extraneous circumstances, or of inability on the part of the pa- 
tient to withstand the shock of the convulsive cough. Thus, the 
congested mucous membrane may, as the result of constant irrita- 
tion, become a fertile culture-ground for bacteria of various sorts, 
so that various inflammatory conditions may result; or the weak- 
ened chest-wall, most of all in asthenic and rachitic children, may 
be unable to withstand pressure, so that pulmonary emphysema 
occurs. In similar ways collapse of lung tissue, surgical emphy- 
sema, thrombosis of the intercranial sinuses, prolapse of the rec- 
tum, or hernia may readily result. It is no uncommon thing to 
find considerable enlargement of the bronchial glands, which may 
make the cough still worse than it otherwise would be. 

Symptoms. — The infectivity of this disease is supposed to be- 
gin as soon as the catarrhal symptoms appear, and to last as long as 
the characteristic cough persists. The exact limits are, however, 
hard to set. The whole early history of whooping-cough is more 
or less indistinct. As an example of this, one may cite the usual 
statements that the incubation period is a fortnight at the most and 
two to four days at the least, and that no symptoms before the 
catarrhal ones are present. Nevertheless, Illoway has noticed a 
short, hacking cough that shows itself without noticeable changes 
or symptoms in the throat and lungs a month or less before the 
onset of the well-known symptoms, and this he considers pathog- 
nomonic. I have been able to verify his observation, but only 
in a few cases ; the small number may possibly be due to the 
deficient faculty of observation in mothers and nurses. 

With the so-called catarrhal stage, the general picture is that 
of an ordinary cold. The child is listless, easily fatigued, poor in 
appetite. There is a cough of ordinary severity that gradually 
shows a disposition to become worse at night ; there may be a rise 
of temperature of one or one and a half degrees, principally in the 
evening. At this time auscultation discovers almost no signs of 
disease in the lungs, or at most a little harshness in the breathing, 
and an occasional rale. 



THE SPECIFIC INFECTIOUS DISEASES 445 

The length of the catarrhal stage is not fixed ; in some it is a 
few and in others it is many days. But the change in the main 
symptom soon becomes clear and striking. A spasmodic element 
then makes itself felt ; the cough comes in a series of quick, hard 
hacks until the air in the chest is exhausted, when with a strong effort 
the air is sucked through the narrowed and rigid larynx, making 
the well-known crowing sound. The patient when this begins 
fixes himself as strongly as he can to withstand the shock ; he bends 
over and grasps a chair, or his knees, or a friendly arm or hand ; 
his face becomes puffed out, dark red or purplish ; his eyes become 
suffused and bulged out, and from mouth and nose a rough flow of 
saliva and mucus bursts forth. Such a paroxysm may be repeated 
time and again, until the child falls to the ground, or lies exhausted 
in the attendant's arms. 

These attacks may come with varying frequency ; as the dis- 
ease progresses they occur oftenest at night, and one of the 
first signs of the approaching end of the sickness is the decrease 
in frequency of these night paroxysms. After the cough the child 
commonly vomits, especially if he has recently eaten. Particular 
attention should be called to the fact that adenoid vegetations will 
increase the severity and prolong the course of the attacks. Occa- 
sionally one meets a case in which the vomiting comes before the 
cough. The two facts point to a central as well as a local gastric 
irritation. When the paroxysms are severe, there may be an invol- 
untary passage of urine and fasces. Regularly during the crisis 
the heart action becomes progressively more rapid until at times 
one is unable to count the pulsations. 

There are many secondary conditions which may supervene : 
hemorrhage, usually unimportant, may occur in any mucous mem- 
brane, especially that of the nose ; in one case I saw the conjunc- 
tivae completely colored by a thin layer of blood from a small rup- 
tured vessel. The lids may be heavy and discolored from ecchy- 
moses ; even the skin of the face may be puffed out and blotched. 
During dentition a small ulcer may be produced on the sublingual 
frenum by the scraping of the tongue, during the spasms, on the two 
lower central incisors. In the lungs there is in typical cases some 
degree of emphysema ; in addition the thinned walls of the air vesi- 
cles may break under pressure, allowing the air to make its way 
into the cellular tissue of the face and body. In other cases vary- 
ing degrees of bronchitis, or broncho-pneumonia, or lobar pneumo- 



446 THE MEDICAL DISEASES OF CHILDHOOD 

nia may supervene. Serious cases of laryngitis are not common, 
nor are well-marked examples of collapse of the lung. The 
stomach and intestines easily become deranged, and may even 
occasionally fall into really serious conditions of gastritis and 
entero-colitis. 

The nervous symptoms in some degree are commonly seen. 
There is always some restlessness and irritability ; there may in 
addition be a tendency to spasm of the glottis and to convulsions. 
Usually after such a seizure the patient quickly regains his ordi- 
nary appearance ; if, however, this recovery is delayed, if stupor 
persists, one should suspect cerebral, usually meningeal, haemor- 
rhage. Paraplegias and hemiplegias of all sorts may come with or 
without such a prelude, the particular form depending upon the 
location and extent of the haemorrhage. 

Finally, great stress should be laid upon the exhaustion which 
falls upon pertussis patients : the long, tiring sickness, the defi- 
cient nourishment, made so by gastric irritability, the disturbed 
rest, and the presence of complications, — all these are factors in 
wearing out the child. He is in a favorable condition to contract 
disease, and especially is he liable to contract tuberculosis. 

Treatment. — The first care is to provide against the infection 
of other children. There may be considerable trouble in doing 
this, for the patient in the intervals between paroxysms resents 
being too closely confined. In the inclement weather of winter 
and spring, when the disease is most prevalent, it may be possi- 
ble to keep him in one or two rooms ; but in summer and autumn 
this is out of the question, especially as the period of infectivity 
extends over the whole active range of the disease and until the 
convulsive element in the cough has vanished. Since it is imprac- 
ticable to confine the patient to his room, the only other plan is to 
remove the healthy children to a safe locality. At all events the 
patient should not be allowed to associate with other children, 
even in the open air, until he is practically well. His apartments 
do not require other disinfection than what thorough cleansing and 
air give. The towels, handkerchiefs, and personal linen should be 
well boiled before being put where they can spread the infection. 

The medicinal care is simple. Almost every drug within the 
range of the anti-spasmodics has been used and recommended by 
some one, and many claims have been made that common experi- 
ence could not endorse. On the other hand, some observers 



THE SPECIFIC INFECTIOUS DISEASES 447 

believe that no drug is of any real use, and that the disease must 
wear itself out. Both views are extreme, and the truth lies 
between them. While there is no drug that acts as a specific, 
nevertheless, in antipyrine we have a remedy that will materially 
mitigate the violence of the paroxysms, and, as I believe, in many 
cases, shorten the attack. But it must be given fearlessly, in com- 
paratively larger doses than an adult would take. For the past 
three and a half years I have been so prescribing it without bad 
effects, the sole precaution being to add to each dose a stimulant, 
usually aromatic spirits of ammonia. The dose which I commonly 
use is 0.06 gramme (one grain) for each year of life up to 0.45 gramme 
(seven grains) every four, three, or even two hours. In exceptional 
cases of tolerance, where necessity demands, the dose may even be 
slightly increased. The next best remedy is bromoform, in the 
same dose in minims, and used with the same precautions. Another 
useful measure is to spray out the nose and throat with an alkaline 
antiseptic solution several times a day. This, I believe, is superior 
to the making of topical applications b}^ means of swabs or brushes, 
which so commonly have the effect of exciting new paroxysms of 
coughing. This can be demonstrated by touching the back of the 
throat, and especially the arytenoid cartilages, with any instru- 
ment, with the almost constant result of a fresh spasmodic attack. 
In fact, a practical method of diagnosis is, while examining the 
mouth, to touch the back of the throat with the tongue depressor, 
whereupon the characteristic cough is commonly elicited. The 
practice of providing medicated vapors seems of doubtful utility. 
With very young children such means can be used only when the 
atmosphere of the whole room is well charged with the remedy ; 
if this is thoroughly done the harm to be derived would in all 
likelihood be greater than the possible good. Just as much benefit 
will be derived from moistening the air, if it is too dry, by steam 
without medicinal admixture. 

The vomiting in some cases is so severe as to call for careful 
consideration. In most cases, as the violence of the paroxysms 
falls under the control of antipyrin, the stomach becomes less 
irritable. In a few cases it may be necessary to regulate the food 
very carefully, or to predigest it, giving it in small quantities. 
Eustace Smith recommends cocaine in doses of 0.01 gramme 
Q grain) twice a day for a child one year old. A few extreme 
cases will be benefited by giving no food at all by the mouth, the 



448 THE MEDICAL DISEASES OF CHILDHOOD 

child being supported for a few days by means of nutrient 
enemata. 

The general care and nursing of the child should be as good 
as possible. So long as he has no fever and the weather is good, 
he should be carried into the air every day. Daily sponge baths, 
so long as precautions against draughts are observed, are bene- 
ficial; and everything possible to soothe the patient's irritated 
nerves, and keep him contentedly occupied should be done. 
Toward the end of the sickness a tonic should be administered 
to combat the inevitable weakness and anaemia. 

Complications should be treated according to their various 
indications. 

Prognosis. — In infants, especially those who are weak or 
rachitic, pertussis is a very serious disease. Their weakness neces- 
sarily restricts within small limits the amount of medicine which 
we may prescribe, they are quickly exhausted by the convulsive 
strain of the cough and the interference with retaining food, and 
they are most susceptible to the various complications. Among 
such patients the mortality may easily be from fifteen per cent to 
forty per cent. With each succeeding half year the danger rapidly 
decreases, and at four or five years of age a death from this disease 
is rare. The complications, such as broncho-pneumonia, tuber- 
culosis, and entero-colitis are to be feared according to their sev- 
eral characters. 

The time length of the disease is very uncertain, ranging from 
two weeks to two months, and in unusual cases possibly longer 
Scrupulous attention and good management will, I believe, make 
these very long cases exceptional. 

Differential Diagnosis. — The early diagnosis of pertussis is not 
often a matter of certainty. If there is a history of prevalence of 
the disease, of a short, hacking cough for days or weeks, unat- 
tended by physical signs in the throat or lungs, of a later cough 
which steadily becomes worse, especially at night, without being 
controlled by the ordinary means, if the physical signs continue to 
be insignificant in proportion to the cough, and if this cough finally 
becomes convulsive, the diagnosis of whooping-cough can be made 
with a reasonable degree of certainty. One source of serious con- 
fusion is the enlargement of bronchial glands to a sufficient degree 
to produce an irritable cough ; but in this case pressure symptoms 
would likewise be present. The ordinary throat and lung diseases, 



THE SPECIFIC INFECTIOUS DISEASES 449 

among whose symptoms would be a cough, have physical signs that 
make them easily distinguishable from pertussis. 

Epidemic Influenza 

La grippe is in many ways one of the most remarkable diseases 
which we are called upon to treat : it has been known for centuries, 
but, nevertheless, unless it comes in epidemics it frequently is not 
recognized ; it attacks all ages, but in some epidemics adults are 
more affected, while in others the disease shows a greater affinity 
for children ; the direct mortality is small, but the depression which 
the disease produces and the liability to long continued or fatal 
after-sickness is great; the cause is single and specific, but its 
manifestations are manifold and diverse. 

Cause. — The active cause of the disease is a minute bacillus 
(0.4 m. x 0.8 m.) which Pfeiffer was the first to describe accurately. 
Its culture-ground is on the mucous membrane of the nose, 
throat, and lungs, where it occurs in large numbers. Its habitat 
suggests immediately its manner of infection as well as the most 
direct method of disinfection. 

Lesions. — The pathological changes are confined for the most 
part to the mucous membranes primarily, from which they may 
spread in various directions. As far as one can see, they are no 
different from ordinary catarrhal processes of the bronchi, trachea, 
larynx, pharynx, nose, ears, eyes, stomach, and intestines. The 
intensity of the inflammation is irregular, and varies not only 
between different epidemics, but also between individuals. The 
main and most serious change seems not to be clue to the direct 
effect of the poison, but rather to the ease thereby produced for the 
entrance and development of other pathogenic micro-organisms, 
such as streptococci, the specific bacilli of lobar pneumonia and 
diphtheria. 

Symptoms. — The period of incubation before the symptoms 
appear is a short one, probably not more than five or six days, and 
generally about half that time. Then the signs break out sud- 
denly, and often with violence. The violent symptoms usually 
last for less than a week, although one occasionally sees a case 
that lingers on for a week or ten days longer. The child com- 
plains of pain in the head, frontal, and orbital, and in the back. 
These may be so severe as to make the patient cry out, and to 
2g 



450 



THE MEDICAL DISEASES OF CHILDHOOD 



frustrate any attempts to obtain an easy position. There will be 
some fever which rarely exceeds 39.5° or 40° C. (103.1° or 104° 
F.) in ordinary cases. While there is nothing characteristic about 
the fever curve, one may notice that its variations, especially its 
rises, do not necessarily carry with them a proportional increase in 
the pulse-rate. The heart does not work very well, and its beating 



PULSE 


RESR. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


170 


70 


FAHR. 

108 


CENT 
42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


41.1 
































HO 


55 


105 


40.5 
































130 


50 


104 


40.0 
































120 


45 


103 


39.4 
































110 


40 


102 


38.8 


/ 


•^ 


^**«. 


/ 


/ N < 


V 


\/ 






\~\ 
\ \ 












100 


35 


101 


38.3 


/ 
/ 
/ 










V 
/ 




•\ 








\ 








90 


30 


100 


37.7 




1/ ' 


V 


\ 


/ 


V 




■ 








V \ 


\ 






80 


25 


99 


37.2 


// 


















\s 


>s*' 




v y 


\ 




70 


20 


98.6 


37.0 




























'Va 


/>*" 


98 


36.6 




























\ 




60 


15 


97 


36.1 







































































PULSE, RESPIRATION AND TEMPERATURE CHART OF INFLUENZA. 
AGE, 10 YEARS. 

PUL8E PFQPIPATION TCMPFPAT1IPF 



Fig. 86. 



gives the observer the idea of weariness. There may be one or 
more chills, followed by profuse sweats. The tongue is coated 
with a creamy fur, the breath has a disagreeable musty odor, and 
the teeth may be covered with sordes. 

In most cases the source of the attack spends itself upon the 
mucous membrane of some part of the body, the selection being 



THE SPECIFIC INFECTIOUS DISEASES 451 

doubtless clue to au existing weakness of the locality in question, 
or to the presence of some particular organism that finds in the 
irritated surface its proper culture-ground. Thus there is a class of 
cases in which the lungs bear the brunt of the attack. There may 
be a bronchitis of any degree of severity, in infants involving the 
smaller tubes ; in older children the lung tissue itself is involved 
so that there is a broncho-pneumonia or an acute lobar pneumonia. 
In these cases, especially the latter, there is apt to be a compli- 
cating pleuritis. One should keep in mind that such a pleuritis, 
whether it occurs immediately, or only as an extension of a pneu- 
monitis, has a strong tendency to become purulent. In all these 
sicknesses one of the most striking features is the weakness of the 
heart, and the consequent general depression. In close relation 
stand the cases in which the heart seems deeply affected by the 
poison of the disease. The beat is at times alarmingly weak, 
irregular, or even dicrotic. In some children there may be cyano- 
sis, oppressed breathing, or even syncope ; the pulse-rate may be 
unnaturally fast or slow, and even after convalescence may take 
long to regain its natural quality. It is possible in rare cases to 
find a thrombosis as a result of the circulatory insufficiency. 

In other children the main symptoms show themselves in the 
nose and throat. There may be a follicular tonsillitis, or a stoma- 
titis, or a laryngitis of one or other variety, or a rhinitis with an 
acrid, muco-purulent discharge ; under these circumstances there 
would naturally be an enlargement of the corresponding glands. 
These disorders of the throat are oftener in children than in adults 
complicated by disease of the middle ear, which may occasionally 
involve mastoid disease. In two cases during the past winter I 
saw emp} T ema of the antrum of Highmore. 

The nervous manifestations are multiform. The pain in the 
head, back, and extremities, convulsions, the stupor or mild delirium, 
are phenomena that one must be prepared to treat. These latter 
symptoms may at times remind one of a meningitis; while in 
other cases the patient is so indifferent and dull as to suggest the 
typhoid condition. Occasionally in older children one may see 
neuralgias of various distribution, which may later develop into a 
distinct neuritis. 

Frequently there may be derangements of the stomach and 
intestines ; these in children are apt to be very often present in 
some degree even when they are not among the main characteristics 



452 THE MEDICAL DISEASES OF CHILDHOOD 

of the disease. The vomiting commonly occurs earlier than the 
diarrhoea, while the latter is more apt to be persistent and at times 
severe. In serious cases, especially where the type of the disease 
is more septic and malignant than the ordinary, there may be an 
acute degeneration of the kidneys which in rare cases is exag- 
gerated into an acute nephritis. 

In epidemic influenza there is always a wide range of possibility 
through which the severity of the case may pass. And at any 
time the symptoms may assume so threatening a form that doubt 
as to the true nature of the disease may logically exist. Thus it 
is impossible to set hard and fast limits to the various phenomena 
that may show themselves in this case or that. The convalescence 
is apt to be long and trying. 

Treatment. — In the absence of a specific drug, the care of 
these cases is symptomatic and general. The precaution should 
be taken to disinfect or destroy the handkerchiefs which the 
patient uses, and also to place in the cuspidores that are in the room, 
a solution of carbolic acid, or some other efficient disinfectant. The 
sick-room on being vacated should be thoroughly cleansed and aired. 
The patient's nose and throat should be carefully, thoroughly, and 
frequently sprayed with an alkaline antiseptic solution. The 
child should be kept in bed and the diet restricted to fluids. He 
may receive sponge baths daily, and if his temperature runs above 
39.5° C. (103.1° F.) he may be treated with the cold pack or the 
graduated cold bath. The pains which are so formidable a part of 
the early symptoms may be kept in check by frequent doses of 
phenacetin and salol (0.12 gramme — gr. ij of each, every two hours 
for a child of five years). The heart weakness may be combated 
by liberal doses of strychnine, and throughout the whole disease 
alcholic stimulation may be indicated. The various complications 
must be treated according to their various needs. 

The treatment of the convalescence is of the utmost importance. 
The diet, bathing, exercise, and general mode of life should be 
carefully regulated. For weeks and even months the child 
should be kept upon tonics, and if possible should be sent into the 
country for an extended vacation. 

Prognosis. — The main danger for children, as for adults, resides 
not so much in the disease itself as in the various complications 
and sequels which are so apt to occur. The worst of these are 
the acute lobar pneumonia, broncho-pneumonia, and pulmonary 



THE SPECIFIC INFECTIOUS DISEASES 453 

tuberculosis. Not often does a child die from influenza alone, 
but frequently enough he may be left in a weak, irritable, and 
debilitated state for many months. At times it seems almost 
more than we can accomplish to get him back to rugged and 
blooming health, and in some cases we are quite unsuccessful. One 
discouraging feature about these complications is that they com- 
monly rage with a greater fierceness than when they occur as 
primary diseases. Throughout the whole sickness the main object 
is to conserve the patient's strength and to ward off as well as 
possible anj r complications. 

Differential Diagnosis. — The crucial point in diagnosis is the 
existence of much prostration, fever, and pain without correspond- 
ingly marked physical signs. This, and the course of the disease, 
will ultimately, even if at first there is doubt, clear up the matter. 
Meningitis, on account of its peculiar course, would within a day 
or two stand out clearly ; pneumonia would give its character- 
istic signs and rapid pulse ; typhoid and malaria would be differen- 
tiated by their especial temperature curves. In many instances 
the diagnosis cannot be made immediately. The simultaneous 
existence of an epidemic naturally makes the case much simpler, 
for the greatest confusion exists in the sporadic attacks. 

Lobar Pneumonia 

Lobar pneumonia, sometimes called croupous or fibrinous pneu- 
monia, is an acute inflammation of micro-organic origin. While 
it generally locates itself in one lobe of a lung, it may on the one 
hand be confined to a mere spot, and on the other may cover a 
whole lung. Its infectious character is so plainly marked that 
it sometimes occurs in epidemics ; often a house or a room contain- 
ing the germ will infect persons living therein, so that one mem- 
ber of a family after another will suffer from it. Although young* 
adults fall victims to it frequently enough, nevertheless children 
of all ages are not susceptible in quite the same degree. Indeed, 
it does not often occur before the age of three years ; but from 
that time until the tenth year it is most frequent. After this time 
the danger of its occurrence lessens progressively. Boys seem to 
be slightly more liable to it than girls ; it is more prevalent in 
spring than in other seasons ; it attacks robust as well as weak 
children. For all these facts it is hard to find a reason ; and 



454 



THE MEDICAL DISEASES OF CHILDHOOD 



similarly it is hard to account for the greater frequency of in- 
vasion in certain parts of the lungs. Some observers, after having 
collected many cases, believe that the base of the left lung is most 
easy of attack, that the apex of the right lung comes next, and 
that the base of the right and the apex of the left follow after. 
Others believe that both lungs at their bases are about equally 
liable, and that the apices are less commonly the seat of the sick- 
ness. The gist of the matter seems to be that, whatever part of 
the lung tissue is attacked, one may feel fairly sure of the fault's 




Fig. 87. — Lobar Pneumonia : First Stage, x 250. 



lying in the weakness of the diseased area, not in a predilection of 
the germ for any definite part. 

Causes. — The cause may be almost regularly attributed to the 
germ called, on account of its shape, Micrococcus lanceolatus. In 
a few cases the micro-organism has not been found; and especially 
is this apt to be true in those cases where the pneumonia compli- 
cates or directly follows another microbic disease. This germ 
occurs not only in disease, but is also found in the sputum of 
healthy persons. While acting as the causative factor of lobar 
pneumonia, it sometimes occurs in other disorders, such as broncho- 
pneumonia and acute exudative inflammations of serous mem- 



THE SPECIFIC INFECTIOUS DISEASES 455 

branes. Thus it has been observed in meningitis, empyema, 
peritonitis, endocarditis, and pericarditis. It has been seen in 
acute inflammations of joints, as well as in purulent inflammations 
of the tonsils and middle ear. Its development is attended by the 
production of an albuminous poison called pneumo-toxine. This is 
the direct toxine of the disease, and shows its power in the symp- 
toms of a general toxaemia. Some experimenters hold that the 
physical economy in the course of the sickness elaborates a cer- 
tain substance which acts as an antidote to pneumo-toxine. When 




Fig. 88. — Lobar Pneumonia: Second Stage. X 180. 
(Eed Hepatization.) 



these two forces meet and offset each other, the approximate 
balance of health is restored, and shows itself in the so-called 
crisis. 

Lesions. — The morbid changes which arise are quite charac- 
teristic. At first the affected parts are heavy, congested, and 
slightly increased in size. The air-spaces become choked with the 
products of inflammation : red and white cells, broken-down epi- 
thelium, and fibrin. The capillaries in the walls of the air-spaces 
are dilated and hold a larger percentage of white cells than usual. 



HBBHHB ^ aHHBBHHjBHIBBBBanBaa ^ 



456 



THE MEDICAL DISEASES OF CHILDHOOD 



The tissue, on account of its engorgement, takes on a dark red 
color, and may become so choked up as to contain no air. 

When this process of filling up is thoroughly developed, the 
lobe is solid, the air-spaces are plugged with small masses of 
inflammation products, the alveoli are full of a serous fluid hold- 
ing many epithelial and white blood-cells, bacteria, and much fibrin. 
The color is somewhat lighter than in the preceding or congestive 
stage. The lung may be then so much swollen as to show, like a 
cast, the shape of the ribs. On section one sees a multitude of 
small elevations, representing the filled-up alveoli. The whole 



















Fig. 89. — Lobar Pneumonia : Third Staee. X 250. 



appearance resembles so much that of the liver that we call this 
stage the period of red hepatization. The inflammation is so 
intense that it overflows the parenchyma of the lung and extends 
to the smaller bronchi or the pleura. 

After the stage of red hepatization is fully developed, the color 
begins to change gradually to yellow and gray. The exudate then 
on account of fatty degeneration begins to soften, and should be 
absorbed. The time of absorption or resolution naturally varies 
according to the amount of material to be consumed and the 
eliminating powers of the patient. 



THE SPECIFIC INFECTIOUS DISEASES 



457 



In some cases the exudate with the surrounding lung tissue 
breaks down and an abscess results. This may become encapsuled 
or absorbed, or go on to a fatal gangrene. 

Symptoms. — The physical signs are occasionally not very dis- 
tinct on the first, second, or even the third day ; after that they are 
clear enough. The child is seen to lie for the most part on the affected 
side, thus preventing free expansion, while the unaffected lung is 
left free to do the work of both. Fremitus is increased and is dis- 
tinguishable when other signs are not marked. Resonance is im- 




Fig. 90. — Lobar Pneumonia : Third Stage. X 250. 
(Fibrin Threads.) 



paired ; breathing is at first rough, and later on bronchial. In 
the full development of the disease one generally finds fine crep- 
itant rales which are heard most plainly on the borders of the 
inflamed area ; in addition there may be some coarser rales, moist 
or drj T , scattered here and there, which are due to a natural ex- 
tension of the inflammatory process. Also, the unaffected lung, 
on account of its increased work, becomes somewhat dilated in a 
part of its air-spaces, and thus gives harsh breathing and an in- 
creased resonance. 

It is commonly supposed that the plrysical signs in acute lobar 



458 THE MEDICAL DISEASES OF CHILDHOOD 

pneumonia may sometimes be absent. This is due to the fact that 
at times the area involved is so small as easily to be overlooked, 
most of all if the inflammation is located deep in the centre of 
the lung. One should also keep in mind that the inflammation 
may extend in such a manner that one hears the signs of a bron- 
chitis or a pleurisy. Or the exudate may be so profuse as to over- 
flow its original limits and fill up adjacent alveoli and bronchioles. 
Thus again one may hear physical signs that are outside of the 
classical form. Also, when resolution sets in the exudate, prepar- 
atory to being absorbed, begins to soften. This may frequently 
give rise to confusion, because various parts of the affected tissue 
may at one time be in different degrees of consolidation and reso- 
lution. This is a more common condition in infants than in older 
children, and much more than in adults. 

The disease may or may not begin with a chill, vomiting, or 
convulsions ; on the whole the* first does not so regularly occur in 
young children as in older patients, while the others are almost 
confined to children. In addition there may be beginning attacks 
of diarrhoea in a fair number of children. It is common to have 
the picture of a healthy child suddenly attacked with high fever, 
rapid and labored respiration, hurried heart action, short, dry 
cough, flushed cheeks, pain in the chest near the affected area, or 
somewhat removed from it, and the additional symptoms depend- 
ent on a disordered alimentary track, or the involvement of other 
viscera. Especially is the spleen apt to be enlarged. 

Since the germ of lobar pneumonia makes its way to regions 
outside of the lungs, one may find symptoms which are character- 
istic of the invaded part. Thus if the meninges are affected, 
stupor or delirium may result ; in a like manner the peritonseum 
may become the seat of inflammation. In this way arose the 
unfortunate terms " cerebral pneumonia," and "abdominal pneu- 
monia." Nevertheless, the truth of the matter is that the pneu- 
monia remains always the same, excepting that in the cases 
mentioned there are added to it symptoms of another disorder. 
Of course one must keep in mind that the stupor may in fact be 
due to the systemic intoxication by the specific poison. 

The usual temperature varies between 39.4° C. and 40.5° C. 
(103° -105° F.) and is characteristic. At times it mounts still 
higher, but in the morning, at least, there are apt to be small 
remissions. Nevertheless, the course is in general fairly regular 



THE SPECIFIC INFECTIOUS DISEASES 



459 



until the crisis, when it suddenly drops to normal or subnormal. 
In the beginning the pulse is small, thin, soft, and rapid, at times 
running as high as 160, or even more to the minute ; it may even 
become dicrotic. Later on it is full and bounding, but not hard. 
The heart is seen to work with difficulty, and the two sounds 
become uneven, the second being plainly accentuated. The respi- 



PUL. 


RESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


170 


70 


FAH. 

108 


CEN. 
42.2 














| 


















160 


65 


107 


41.6 




t 


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,"i 

1 1 


















150 


60 


106 


41.1 




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140 


55 


105 


40.5 




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130 


50 


104 


40.0 




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V', 




i 

1 / 


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120 


45 


103 


39.4 


/ 
/ 


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rv 


•Ik 


V 


iii 




iV 




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1 


1/ 


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110 


40 


102 


38.8 


.LI 


s/IV/l; 


f 






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I 
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100 


35 


101 


38.3 


A 


! 


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If 


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• 

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90 


30 


100 


37.7 


/ 


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V 


V 


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1 1 \ 


v/J 












80 


25 


99 


37.2 












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70 


20 


98.0 


37. 






















\ 










98 


30.6 
































60 


15 


97 


36.1 







































































PULSE, RESPIRATION AND TEMPERATURE CHART OF LOBAR-PNEUMONIA. 
AGE. 11 MONTHS 
pulse respiration temperature 

Fig. 91. 



ration is very fast, so much so that it outstrips the ratio with the 
pulse. Thus one often sees this ratio as one to two and a half 
instead of one to four. During the first day or two the child may 
pause after every few expirations, and give a short, catchy moan. 
One should keep in mind that infants are more subject to high 
pulse- and respiration-rates than adults, and that any of the ordi- 



460 THE MEDICAL DISEASES OF CHILDHOOD 

nary complications may give symptoms which may seem far more 
startling than the true state of the case warrants. It is necessary 
to distinguish between such a condition and one where there is a 
large amount of lung tissue involved, or an unusually severe 
systemic poisoning. A want of harmony between the tempera- 
ture, pulse, and respiration curves is unfavorable. And irregular- 
ity in any of these factors is likewise unfortunate, pointing as it 
does to added disease or failing strength. 

In this disease the patients are apt, partly on account of the 
pain which effort of any sort brings on, to be much quieter than 
one would expect from so much general and local irritation. 
This does not, of course, apply to cases of unusually high tempera- 
tures or unusually severe infections ; for here one is apt to find 
delirium or stupor, varying in severity according to the compara- 
tive resistance of the child. Such symptoms have helped to bring 
about a belief that meningitis, tubercular or non-tubercular, very 
often complicates lobar pneumonia. This is far from the truth ; 
although it is a fact that cerebral symptoms are easily developed 
in children who are suffering from a toxic disease, and that a men- 
ingitis may be caused by the pneumococcus, a complicating disease 
is not by any means a common occurrence. 

The crisis is characterized by a sudden dropping of the tempera- 
ture to normal or subnormal, by free, quiet respiration, and a full 
transpiration. The urine, which had been scanty, high colored, 
and sometimes charged with albumin, becomes light colored, 
clearer, and more nearly normal. Occasionally the patient will be 
fortunate enough to have also a free, thorough catharsis, after 
which he will be found to be materially more comfortable. In the 
cases that end suddenly, the crisis may come between the third 
and fourth days, on the fifth, or between the seventh and eighth, 
even as late as between the eighth and ninth. There are some 
exceptions to this — cases, on the one hand, of a slow and gradual 
dropping of temperature, the so-called resolution by lysis ; on the 
other, those rare cases of delayed resolution where the children's 
symptoms may persist for from ten day to three weeks. There 
are occasional examples of a very rapid course that seem to end a 
few hours before the third day. 

This disease is not commonly liable to many complications. 
There is, as has before been stated, a likelihood of more or less 
bronchitis, so that at times one finds the picture of an acute lobar 



THE SPECIFIC INFECTIOUS DISEASES 461 

pneumonia associated with scattered areas of broncho-pneumonia. 
Then again, an extension of the inflammation to the pleura, with 
or without effusion, often enough occurs. As has been stated 
above, there may be a complicating meningitis, which is somewhat 
unusual. Also, one should bear in mind the possibility of an 
associated inflammation of the serous membranes as well as the 
kidneys. And where resolution is delayed, where the pulmonary 
tissue breaks down, one occasionally — or rather rarely — sees a 
gangrene of the affected area. It may be mentioned that infants 
are not able to expectorate, and that therefore one should not look 
for the characteristic sputum ; however, in patients over five or 
six years the adult appearance is gradually assumed. 

Treatment. — The treatment of lobar pueumonia requires 
judgment and thoroughness, rather than the strict adherence to 
a routine. To begin with, it is advisable to discard the poultices, 
pneumonia jackets, and breast pads that for so many years have 
been in almost universal use. Their value is more than doubtful ; 
employment of them is attended by plain dangers. The surface 
of the body should be kept as active as possible, not hindered and 
clogged up. Antipyretics, likewise, are with advantage omitted. 
The mere lowering of temperature is not necessarily of the first 
importance ; where the temperature is lowered with a consequent 
decrease in vitality, one is apt to do more harm than good. 
Where the commonly employed antipyretics are freely given, the 
temperature chart may, it is true, be decidedly altered ; but there 
is very little comfort in having a baby die, even though his 
temperature be normal. 

Moreover, these agents are really not at all required because 
we have safer and more efficient means in baths, spongings, and 
packs. A robust child will bear a graduated bath (down to 60° F. 
— 15° C.) with comfort and benefit. Or one may refresh as well as 
cool him by sponging the body for a period of from ten to thirty 
minutes with lukewarm or cool water mixed with alcohol. Or, 
again, one may, where the other methods are not advisable, use hot 
or cold packs. The main rule is that a robust child in compara- 
tively good condition may be treated with cold water ; but a little 
one who is very weak, whose circulation is poor, whose extremi- 
ties are cold, should by all means have warm applications. And 
when, on account of the application of cold, the extremities 
become cyanosed or chilled, one should directly resort to methods 



462 THE MEDICAL DISEASES OF CHILDHOOD 

of heating the surface. All in all, one must keep in mind that 
practices for lowering the temperature should be kept as clear as 
possible from the suspicion of exaggerating the patient's weakness. 

On the other hand, every effort should from the first be made 
to sustain the patient's strength. One must keep in mind that he 
is suffering, not only from the toxic effects of the disease, but also 
from a defective circulation, and that one of his gravest dangers 
lies in the strain put upon the heart. The stimulation will in 
all likelihood be in continuous demand through the whole sickness, 
and therefore should be accordingly arranged; one should proceed 
cautiously, always remembering that it is wise tokeep a reserve of 
stimulation for occasions of sudden weakness or collapse. One 
of our most useful drugs is strychnine in doses of gm. 0.0005 to 
0.001 ( T |~o to g 1 ^ of a grain) three, four, or five times a day. Nitro- 
glycerin in very small amounts combined with large doses of 
digitalis is also of value, as is likewise strophantus or sparteine. 
In the whole matter of treatment one must pay most attention, not 
merely to the heart as a whole, but rather to the right side of the 
heart. And wisely directed efforts will ameliorate such symptoms 
as nephritis, oedema of the lungs, distressing dyspnoea, and the 
concomitant effects of impeded circulation. 

When the cough is very distressing, it must be quieted ; and for 
this purpose bromide of soda, which the youngest babies tolerate 
well even in large doses, will be found of use. In older children 
it may be necessary to use small doses of opium. But so long as 
this can be avoided, it is better so to do. When resolution sets 
in, expectorants are plainly indicated ; and if by the use of alkalis 
one can render the mucous secretion thinner and more easily 
movable some advantage will have been gained. Even at this 
time the danger of extreme weakness or sudden collapse must 
always be kept in sight and carefully provided for. The use of 
oxygen has not as many adherents as in past times, for various 
competent observers have declared that the mortality of their cases 
is not at all lessened, nor the comfort of the patients improved by it. 
In spite of this opinion, which is doubtless correct, the inhalations 
of the gas continue to be used. 

A suggestion, that has some value, has of late been receiv- 
ing renewed emphasis : it is that the amount of food should be 
restricted. It is urged that a full stomach diminishes the amount 
of space which the swollen lung ought to have, and that the gas- 



THE SPECIFIC INFECTIOUS DISEASES 463 

trie enlargement is easily increased if fermentation of the contents 
occurs. It is held that for the short period of the pneumonia the 
child can easily be maintained on a reduced diet, especially if he 
is receiving alcoholic stiinulants. 

Some very encouraging experiments with a pneumonia anti- 
toxine have been made ; but since they are as yet confined to thu 
limits of research, they should not receive further mention. 

Prognosis. — The prognosis is, on the whole, fairly good, since 
no more than from two per cent to four per cent should die ; in 
very weak children or where there are complications which diminish 
the amount of available lung tissue, or increase the inroads upon 
the general strength, there is naturally an important element of 
added danger. When death occurs, one can see the strain which 
the impeded circulation put upon the heart by its relaxed, slightly 
dilated condition. And when it stops it is in diastole. 

Differential Diagnosis. — The main signs of high fever, rapid 
respiration, cyanosis, and cough, plus the physical signs in one 
lobe or in one lung, make the diagnosis of this disease fairly plain. 
Nevertheless it has been overlooked or mistaken for other sick- 
nesses, some of whose symptoms are more or less related. Thus 
the sudden prostration with cerebral symptoms has suggested 
meningitis ; but in this disorder the respiration and pulse are slow 
and irregular, while in pneumonia they are rapid ; in meningitis 
the cerebral symptoms increase as the case progresses, but in pneu- 
monia they decrease ; in meningitis physical examination does not 
implicate the lungs at all. Lobar pneumonia has been confused 
with malaria, gastritis or gastro-enteritis, measles and scarlet fever, 
tonsillitis, and, most of all, broncho-pneumonia. Malaria has its 
history of exposure, its characteristic fever and chill, and freedom 
from pulmonary disease. Scarlet fever and measles present their 
eruptions and frequently a history of exposure. Tonsillitis is dis- 
tinguished by the appearance in the throat, and although the^e may 
be a cough, the signs of consolidation are absent. Broncho-pnea- 
monia commonly attacks infants, while lobar pneumonia is rarely 
seen under three or four years of age ; in the former the onset is 
commonly gradual, in the latter it is abrupt. In the first the process 
is diffuse, in the second it is circumscribed. In the former the 
disease is commonly secondary, while in the latter it is almost 
always primar}^. In the one the signs of consolidation are com- 
bined with those of a marked bronchitis, but in the other the con- 



464 THE MEDICAL DISEASES OF CHILDHOOD 

solidation gives the main or only signs, and if a bronchitis is 
present it is easily recognized as of subsidiary importance. In 
broncho-pneumonia there is no typical course, the disease may last 
for weeks, and commonly ends by lysis; but in pneumonia the 
course is typical, rarely extends over eight or nine days, and ends 
by crisis. The prognosis in the former is serious, in the latter it 
is comparatively good ; and when the disease is past, the broncho- 
pneumonia is often enough followed by chronic pulmonary disease, 
while lobar pneumonia is rarely so attended. The resolution in the 
one is slow and halting, but in the other it is rapid and complete. 

Lobar pneumonia is distinguished from purulent pleuritis by 
the latter's fluid, and the signs which fluid necessarily produces. 
The opinion can be confirmed by aspiration, even if the examiner 
is unable to satisfy himself concerning the usually plain evidences 
of consolidation. 

Enteric Fever 

Typhoid fever, as it is usually called, is an acute infectious 
disease that is more commonly seen in adults than in children. 
Nevertheless it occurs at all ages, from foetal life to old age ; in 
children under two years of age, doubtless on account of their 
comparatively sterile food, the disease is not often seen. After 
that infection becomes more and more common, until it reaches 
its fullest occurrence in youths and young adults. 

Cause. — The specific cause of enteric fever is Eberth's bacil- 
lus, a short, thick organism whose ends are rounded, and from 
which eight to twelve flagella project. The vitality of this bacil- 
lus is noteworthy ; freezing does not necessarily kill it, but con- 
tinued exposure to temperature over 100° C. (212° F.) is fatal. 
When dried it has been known to live over two months. On food, 
milk, water, dirt, refuse, and ordinary household utensils, it is able 
to exist for periods varying from one week to two years, the best 
environment predicating the absence of sunlight and air. The man- 
ner of transmitting it is thus easily understood: it is carried from 
the body in the faeces, and doubtless the urine and sputum as well. 
It then finds its way into refuse, sewage, cesspools, and rivers. 
Thence it contaminates articles of food and drink, and thus is 
taken once more into the gastro-intestinal track. In other cases 
it may be carried by hands which have become infected to the 
mouth, and thus equally well finds an entrance to the body. 



THE SPECIFIC INFECTIOUS DISEASES 



465 



Lesions. — The characteristic changes occur in the intestines 
and spleen ; but, in addition, there are various others that may be 
seen in different parts of the body according to the severity of the 
disease. As a rule, typhoid fever runs a mild course in children, 
and the pathological changes are, therefore, not extreme. In the 
intestines they are, for the most part, grouped in the lower ileum 
near the ileo-csecal valve ; this does not preclude the involvement 
in scattered patches of other portions of the large intestine or of 
the small intestine. The process occurs most fully in the follicu- 
lar elements. There is first an inflammation of the mucous mem- 




Fig. 92. — Typhoidal Swelling of Lymph-Node. X 30. 



brane which spreads to the underlying follicles and lymphatic 
glands. The different elements which go to constitute a Peyer's 
patch may not be equally involved, and the resulting appearance 
is one of unevenness. With this there is a considerable infil- 
tration of both solitary and agminated glands; the enlargement 
may be so great as to cause a noticeable projection into the 
lumen of the grit. These affected follicles then soften and break 
down, leaving an ulcerated surface behind them. The portion of 
the bowel which remains intact may be exceedingly thin. The 
bacilli from the intestine make their way through its walls into 
2h 



466 



THE MEDICAL DISEASES OF CHILDHOOD 



the lymphatic tissue, and thence into the mesenteric glands and 
the blood. The mesenteric glands undergo similar changes as 
in the gut, and may go on to suppuration. Although the typhoid 
bacillus may cause suppuration, nevertheless such a process is usu- 
ally one of mixed infection ; in either case, however, the result is 
a purulent peritonitis. The spleen is affected in somewhat similar 
ways as the intestines. One of its most marked changes is its 
increase in size. This begins at the first stage of the disease, and 
continues for about two and a half w T eeks in young children and a 
somewhat longer time in the older ones. The swelling may be 




Fig. 93. — Typhoidal Ulceration of Intestine. Healing Stage. X 30. 



so considerable as to stretch the capsule. At the same time the 
stroma becomes indistinct, the parenchyma soft and pulpy, and 
the whole organ infiltrated with leucocytes. Infarctions may occur 
after the first stages of growth and may result in peritonitis. This 
last-named complication may likewise occur from an extension of 
the inflammation through the serous coat of the gut even when 
the ulcer has not caused perforation. When perforation does 
occur the amount of peritonitis is naturally much greater. 

The whole gastro-intestinal track may become, to a greater or 
less extent, involved. From the mouth to the rectum there may 



THE SPECIFIC INFECTIOUS DISEASES 467 

be various degrees of inflammation, varying in different cases in 
severity as well as location. The pharynx may be congested and 
inflamed, the tonsils may be enlarged, and the follicles may be 
involved in the attack ; at the same time the associated submaxil- 
lary glands, and even the parotid gland, may be swollen and tender. 
In well-marked cases there may be an acute degeneration in the 
pancreas and liver, but the latter viscus does not appreciably 
increase in size. The heart shows a tendency to atonicity, is pale, 
and the muscular fibres may be degenerated. The larynx is apt 
to fall into a catarrhal inflammation which only rarely in children 
assumes a serious form. The lungs easily become irritated, show- 
ing the changes of acute bronchitis. When the child is weak, and 
in the presence of the proper micro-organic life, the transition to a 
broncho-pneumonia or an acute lobar pneumonia is easy. The 
kidneys, as in all acute infectious fevers of much severity, are com- 
monly irritated. There is often, even when the clinical s}-mptoms 
do not draw attention to these organs, a cloudy swelling of the 
epithelium, an acute degeneration, or even an acute nephritis. In 
children the toxines of the typhoid bacillus have a disproportion- 
ately marked effect upon nerve tissue, as far as the symptoms go. 
In severe cases there may be a hyperemia of the cerebral meninges, 
and some effusion into the ventricles of the brain. Nerve fibres 
are flaccid, and here and there may show minute areas of fatty 
degeneration. 

Symptoms. — From the time when the patient contracts the 
disease up to the appearance of the ordinary symptoms is a vari- 
able period, the mean of which is about a fortnight, while the 
extremes are three days and three weeks. During this period the 
child is commonly irritable or depressed, he tires of his ordinary 
pursuits and games, complains of headache, and possibly intestinal 
or gastro-intestinal disorders. These manifestations are often so 
trivial in their appearance that they escape any especial notice. 
Sometimes the disease begins its usual course, and on account of 
its mild character is not diagnosticated for several days. The 
typical picture of the onset is the occurrence of depression, pains 
in the limbs, headache, anorexia, epistaxis, and gastric disorders. 
There is a rise of temperature, and the child is plainly unfit to be 
about. Usually he asks to be put to bed, and instead of feeling 
better continues to get worse. This is usually considered the first 
day of the disease. 



468 



THE MEDICAL DISEASES OF CHILDHOOD 



One of the main features of the disease is the temperature 
curve. This does not show as high a range of fever as in adults, 
and often the period between its beginning and its end is shorter 
as well. For the first half-week the temperature rises progres- 
sively every evening until it reaches a maximum of from 39.2° to 
40° C. (102.5° to 104° F.). The morning curve shows a fall of 



PULSE 


RESP. 


TEM'P. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


11 


12 


13 


14 


15 


170 


70 


FAH. 
108 


CEN. 
42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


4tl 
































140 


55 


305 


40.5 


















i 

1 

t 


\ 


A 


.' 








130 


50 


104 


40.0 














A 


A 

/ 


1 


V 


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■ 
1 






120 


45 


103 


39.4 










/ 
/ 

/ 


\ i 
\ / 


'/ 




/ 
/ 
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\) 


V 


I 




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110 


10 


102 


38.8 




1 
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' \ 

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ll\ 

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Vvi 




V / 
/ 






v 


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100 


35 


101 


38.3 




7 




fi 


v/ 


\! 










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90 


30 


100 


37.7 


/} 




\v 




/ 

1 


















V 


V 


80 


25 


99 


37.2 






























V 


70 


20 


98. C 


37.0 
































98 


36.6 
































60 


15 


97 


36.1 







































































PULSE, RESPIRATION AND TEMPERATURE CHART OF MILD TYPHOID. 
AGE, 4 YEARS. 

"i>ULSE____ RESP:RATI0N__. __.__. tfmdcpitmpc 



Fig. 94. 



from -| to 1^ degrees C. Generally the respiration and pulse follow 
the fever in a fairly approximate way. The tongue is coated, 
there may be diarrhoea or constipation, the abdomen may be 
slightly swollen and tender, especially in the right iliac region. 
At the end of this period the temperature remains at its approxi- 
mate height, and the difference between the morning and evening 



THE SPECIFIC INFECTIOUS DISEASES 469 

figures is less than before. At the end of the first week, in the 
majorit}^ of cases, a roseola appears in the form of small rose-pink 
spots, disappearing on pressure and usually few in number, on the 
abdomen. There may be one or more crops of them, each crop 
lasting about three days. During this time the tongue is dryer 
and browner than before, the abdomen more distended and tender; 
there may be borborygmi, and sometimes a diarrhoea that is com- 
monly likened in appearance to pea-soup. The patient may be 
semi-stupid or irritable, and in some cases there may be some 
delirium. 

At the end of the second week the severity of the disease 
begins to moderate, but at the same time the increased weakness 
shows that the child has passed through a severe trial. The 
morning temperature shows greater approaches toward the normal, 
followed gradually by the evening fever. The pulse ma}^ be weak, 
irregular, and dicrotic, the heart may be noticeably weak, and the 
patient's resistance against attacks of pulmonary disease is poor. 
If there is delirium, it is apt to be at its worst in this period of 
weakness. Likewise this is the most likely time for intestinal 
haemorrhage, and the evolution of nervous symptoms. Within a 
few days, however, a gradual return to health is made, and in 
children convalescence is commonly uneventful. After the dis- 
ease has ended, one, two, or even three relapses are possible ; 
usually they are of a mild type. 

The main forms of deviation from the normal adult's type 
which we see in children are irregularity in onset, mildness of 
symptoms, markedly so in young children, sparseness or absence 
of eruption, and short course which in some cases may be called 
abortive. Occasionally infants show a temperature that one may 
call remittent. As has been said more than once, typhoid fever 
in children seems to have as many nervous as abdominal character- 
istics ; in some cases the meningeal and spinal symptoms are so 
marked as to make confusion with meningitis eas}'. Likewise the 
possibility of complicating lung diseases is great, most of all 
hypostatic congestion and bacterial attacks which may result in 
bronchitis, broncho-pneumonia, and acute lobar pneumonia. The 
usual course, extensions, and outcome of these diseases may be 
expected. In addition the larynx may be involved, and occasion- 
ally, with or without a similar infection of the rest of the throat, 
becomes the seat of diphtheritic inflammation. This is undoubt- 



470 THE MEDICAL DISEASES OF CHILDHOOD 

edly one of the sources of post-typhoidal paralyses. When any 
disease of the throat prevails, the possibility of middle-ear disease 
should always be kept in mind. 

As there is a wide spread of intoxication throughout the body, 
it is possible that one or other of the viscera may show the effects. 
The kidneys may present the phenomena of degeneration or 
distinct inflammation, and the heart or its serous envelope those 
of inflammation or effusion. Frequently one may notice that chil- 
dren during typhoid fever increase in height to a noteworthy 
degree ; the change occurs rather in the epiphyses than in the di- 
aphyses of the bones, and sometimes is connected with an irritation 
or inflammation of the joints or their cartilages. Lastly, the 
debilitated condition of the economy invites, in the presence of 
the appropriate predisposition, attacks of tuberculosis, especially 
pulmonary tuberculosis. 

Treatment. — Prophylaxis is an important element in the care 
of typhoid cases. All excretions and discharges should be mixed 
with strong antiseptic solutions, such as 1 : 1000 corrosive sublimate, 
1 : 20 carbolic acid, or slaked lime 1 : 200. The patient's bed linen, 
napkins, and towels should be boiled very thoroughly, and not with 
those of the family. His utensils of all sorts should be kept 
separate from the household's ; his hands and mouth should be 
carefully washed before meals, and the nurse should be warned of 
the danger of infection. Where the patient has recovered, the 
sick-room and its contents should be cleansed and aired in the most 
thorough fashion. 

The care of the patient, in the absence of an efficient serum 
therapy, is symptomatic. At the outset of the disease the intes- 
tines should be thoroughly emptied by means of calomel; the 
child should be confined to bed, and his diet restricted to milk. 
Attempts to abort the disease by means of intestinal antiseptics 
have been shown to be fruitless, for the simple reason that unless 
the drugs are administered in doses which are dangerous to the 
patient they are likewise harmless to the micro-organisms. If 
there is diarrhoea it may be treated by large doses of subgallate of 
bismuth, with or without starch enemata in which are mixed a small 
amount of opium. Constipation may be relieved by occasional 
doses of calomel followed by small amounts of salines ; this 
may be varied by the use of enemata of soap-suds and water, 
or water with a little glycerin dissolved in it. Tympanites 



THE SPECIFIC INFECTIOUS DISEASES 471 

calls for the passage of a rectal tube, or the administration of 
enemata with a few drops of turpentine or a small amount of 
inspissated ox-gall mixed in them. The use of hot stupes may 
relieve the abdominal tension and tenderness. The nervous 
symptoms may call for the use of an ice bag, with or without 
fairly large doses of the bromide of soda. The use of stimulants 
should be begun as soon as the first signs of flagging vitality show 
themselves, and it is better to begin somewhat too early than late. 
For this purpose nux vomica, aided by a good whiskey well diluted 
with water, is useful. The main part of the treatment at the present 
time consists in cold or graduated baths given whenever the rectal 
temperature is 39.5° C. (103.1° F.) or more. For robust children 
the former may be selected, at a temperature of about 21° C. (70° 
F.) ; for very young or feeble patients it is better to start with a 
temperature of 37° or 37.5° C. (98.6° or 99.5° F.), at the same 
time paying the closest attention to the reaction of the patient. 
During all these baths the surface of the chest, abdomen, and ex- 
tremities should be rubbed briskly with the hand, and the child, 
as soon as he shows depression, shivers, and turns blue, should be 
taken from the water, put in bed, and his feet warmed with hot- 
water bags. All complications should receive their approximate 
treatment. 

As soon as convalescence is established, the child must be put 
upon a sufficiently prolonged course of tonics. Sometimes marked 
anaemia and asthenia may persist for months. Such cases most of 
all require constant attention and up-building until a normal state 
of health returns. When the circumstances of the patient permit, 
a protracted vacation in the country is of great value. 

Prognosis. — The chances of recovery are very much better in 
children than in adults. Although the usual statistics give a mor- 
tality of from five per cent to eight per cent, nevertheless one may see 
that, since these are the results of hospital experience with doubt- 
less the worst class of cases, the estimates in favorably situated 
families in private practice could safely be put at one half of the 
above figures. In estimating the probable length of the sickness, 
one should remember the shorter course in children, and that the 
usual period of from three to four weeks in adults has its analogue 
in two to three weeks in younger patients. 

Differential Diagnosis. — The main difficulty in diagnosis occurs 
in the first week. In that time such symptoms as headache, epis- 



472 THE MEDICAL DISEASES OF CHILDHOOD 

taxis, pains in the body, abdominal tenderness, and a continued and 
nightly mounting of fever should turn our thoughts to typhoid. At 
the end of the first and the beginning of the second week there are 
the additional symptoms of the eruption, enlarged spleen, tympa- 
nites, continuance of the characteristic temperature, and the added 
severity of the general symptoms. Ehrlich's diazo reaction is not 
of much practical importance, since it is present in other pyrexial 
and apyrexial conditions. Widal's reaction is of much more value, 
especially after the first week. As pointed out by Elsberg (New 
York), more than one trial may be necessary on account of the late 
development in some cases of the " agglutinizing power." Another 
method of differential diagnosis has recently been published by 
Piorkowski. He claims that cultures which are made on urine 
agar from typhoidal faeces will show the typhoid bacillus within 
thirty hours. 

The one disease that is most likely to cause confusion is tuber- 
cular meningitis. But in this disorder the slow, hard, and irregular 
pulse, the normal-sized spleen, retracted abdomen, persistent vomit- 
ing, coma, localized paralyses, absence of typhoid temperature, and 
Widal's reaction will make the matter clear. In other diseases 
there are plainly marked features that lead us aright : in malaria 
we see the peculiar temperature, the plasmodium in the blood, and 
the prompt reply to the administration of quinine. In pneumonia 
there are the rapid respiration and the physical signs in the lungs. 
In acute general miliary tuberculosis there is a plain involvement, 
usually of various parts of the body and commonly of the lungs, 
no eruption, no typhoid temperature or Widal's reaction, and 
often the tubercle bacilli appear in the sputum or the stools. 

Erysipelas 

This is an infectious inflammation caused by a specific micro- 
organism, Streptococcus erysipelatis, that finds its way under 
the skin through small or large wounds. The micro-organism is 
medium-sized, occupying a mid-place in dimensions between the 
staphylococcus and the Streptococcus pyogenes. In former times 
it occurred in epidemics, and regularly in hospitals in infected 
operation wounds. At the present time it occurs in the new-born, 
in accidental wounds and abrasions of the skin, and mucous mem- 
branes of the face and body. It does not necessarily produce its 



THE SPECIFIC INFECTIOUS DISEASES 473 

characteristic eruption at the point of inoculation, and in some 
cases these two localities nia)^ be far separated. An attack evi- 
dently confers immunity for a short time, as Tehleisen has demon- 
strated ; after this immunity has worn off, however, the patient 
may be repeatedly subject to new invasions. 

Lesions. — The principal changes consist in inflammation and 
serous infiltration of the skin and subjacent connective tissue. In 
the lymphatic spaces and vessels of the corium the micro-organisms 
group themselves singly and in chains, clustering for the most 
part about the margin of the inflamed zone. As this zone clears 
up the streptococci die, and are replaced by varying amounts of 
leucocytes. The skin or mucous surface is congested, heavy, and 
filled with serum. In areas, on account of local lack of resistance 
or intense intoxication, the tissue breaks down and may become 
gangrenous. As in other infectious diseases, there may be an 
acute degeneration or inflammation of the abdominal and thoracic 
viscera, which in the presence of specific micro-organisms may take 
on the especial features that belong to their development. In 
this way we may find disorders of the nose and throat, lungs, 
kidneys, spleen, heart, peritonaeum; there ma} T also be inflamma- 
tions of the meninges, or thromboses of the intercranial veins. 

Symptoms. — According to Fehleisen's inoculation experiments 
the period of incubation varies from fifteen to sixty-one hours ; 
clinically we speak in general terms of its being from one to three 
days. In the newly born the common locality of the disease is 
about the umbilicus, in children on the body and extremities, 
while adults have a larger percentage of involvements of the face. 
The invasion usually begins with headache, prostration, often a 
chill and vomiting. The temperature rises rapidly, usually attain- 
ing the maximum about four o'clock in the afternoon ; and at the 
same time the pulse rate keeps in equal step. The throat is 
often dry, hot, and congested. Simultaneously with these general 
symptoms the eruption appears on the skin or mucous membrane. 
Thus an area of inflammation — red, glistening, slightly raised, 
hard, fan-shaped, and sharply marked off — breaks out on the 
abdomen, the extremities, or the face. In the face the usual 
location is at the lower border of the nose, about the mouth, 
on the cheeks, or near the hairy scalp. The tendency of the 
inflammation is to spread irregularly in various directions ; and 
as it spreads, the previously affected part after a period of three. 



474 THE MEDICAL DISEASES OF CHILDHOOD 

four, or five days, gradually returns to its normal condition and 
color. Thus, in one subject, various degrees of irruption may 
simultaneously be seen. As the main area loses its inflammation, 
the temperature falls, the whole skin surface loses its hotness 
and dryness, and may be bathed in sweat. At times, when one 
area is relieved, another, possibly at some distance, becomes 
involved with the natural accompaniment of recrudescence of 
fever and a return of the general symptoms. Such an attack 
has received the name of erysipelas ambulans in distinction from 
the first-described variety, where the eruption, creeping continu- 
ously from one part to its neighbor, is denominated erysipelas 
migrans. Occasionally the skin may have one or more blebs upon 
it, filled with clear or partially clear serum. At these locali- 
ties, or near them, the skin may break down into a superficial 
gangrene. 

In different patients the severity of the disease varies within 
wide limits. In the mild cases there is comparatively little pros- 
tration, pain, or after effects ; in the severe attacks, however, the 
prostration is very marked, the intoxication very serious, showing 
itself in gastrointestinal disorders, and serious cerebral symptoms, 
such as delirium, stupor, or mania. In children, even more than 
in adults, the spread of the disease to the throat is particularly to 
be feared. The mucous membrane throughout the mouth and 
throat may be dark red, much swollen, and infiltrated with serum, 
and here and there small blebs may be seen. These shortly break 
down, leaving a ragged, necrotic background. It is in the larynx 
that the greatest danger lies ; for the tissues may become so much 
swollen that a dangerous laryngeal stenosis may rapidly spring 
up. When the mouth or throat is affected the connected glands 
are enlarged and tender. 

A serious complicating feature is the occurrence of cellulitis. 
When this happens the danger of meningitis, pericarditis, pleuritis, 
and broncho-pneumonia is much increased, General visceral com- 
plications are not uncommon, and in well-marked cases some degree 
of acute renal degeneration is to be expected. 

Treatment. — Prophylaxis in erysipelas is of the utmost impor- 
tance ; not only must the patient be rigorously isolated, but also 
must both nurses and physicians be careful not to act as carriers 
of the disease to other persons, sick or well. Neither nurse nor 
physician should, while attending the disease, treat a wound or 



THE SPECIFIC INFECTIOUS DISEASES 475 

conduct an obstetrical case. When convalescence sets in and the 
inflammation of the skin has subsided, the child may be removed 
to another apartment, and the sick-room must be thoroughly 
cleansed and disinfected. At the onset of the sickness the child 
should be put to bed, his bowels moved by small and repeated 
doses of calomel or a saline, and his food restricted to the simplest 
and most easily digestible articles. The body should be sponged 
daily, and graduated cold baths may be used for the control of 
temperature. Nursing children should either be taken from the 
breast or should suckle through a breast shield. The danger of 
infection must be clearly explained to the mother, as well as the 
best means of warding off the contagion by means of strict anti- 
sepsis. One of the main indications in the care of the patient is 
the necessary active stimulation with strychnine and alcoholics. 
These should be given liberally until all danger is past. The 
skin in mild cases may be covered with moist boric acid dressings 
or very weak carbolic vaseline spread on lint. Severer cases may 
be treated with moist corrosive sublimate dressings covered with 
rubber tissue. Various methods of treatment, looking to an at- 
tempt at limiting the spread of the disease, have been devised. 
For this purpose the affected area has been covered with a rive or 
ten per cent icthyol ointment, or with iodoform collodion : or the 
skin outside of the inflammation has been painted with strong 
solutions of nitrate of silver, or with tincture of iodine ; or the 
extra marginal tissue has been thoroughly scarified and covered 
with wet bichloride of mercury or carbolic acid dressings ; in some 
cases h}'podermatic injections of carbolic acid solutions have been 
made, but the method carries with it a certain amount of danger, 
especially for young children, and therefore should be used with 
great caution. The success of the attempts has not been fully 
demonstrated. Pain must be controlled by opium in older, and 
antipyrine or bromide of soda and chloral for young children. 

Complications should be treated according to their several 
indications. 

Prognosis. — Ordinarily an attack lasts for a week or less, but 
in erysipelas ambulans the disease may extend its course for two 
or more weeks. In strong children in whom the disease is not 
very severe the chances of recovery are very good. In nurslings 
the contrary is the fact ; these patients seem particularly unable 
to stand the sepsis of the disease, and easily fall into collapse. 



476 THE MEDICAL DISEASES OF CHILDHOOD 

Likewise, facial erysipelas is commonly worse in its prognosis 
than that of the body, and likewise gives severer symptoms. All 
in all, an equation must be made between the apparent virulence 
of the attack and the vitality of the patient. 

The differential diagnosis is usually easy. If one keep in mind 
the peculiar eruption, the marked general symptoms, and the 
picture of intoxication, there is no other disease with which ery- 
sipelas can be confused. 

Tetanus 

Tetanus is an acute, infectious disease caused by the bacillus 
discovered in 1884 by Nicolaier, and more fully investigated and 
described by Kitasato five years later. It occurs in children of all 
ages by inoculation ; 'and on account of the large number of deaths 
due to it in the first few days of life, it was formerly included in 
the diseases of the new-born. But there is no especial reason for 
so classifying it, since the active cause is alike in all ages ; nor is 
there any real difference in the symptoms between one time of life 
and another. It is doubtful whether the germ in its purity pro- 
duces the characteristic manifestations as we commonly see them ; 
on the contrary, there is good cause to believe that the presence 
of other pathogenic micro-organisms is necessary to its fruitful 
development. It occurs in the soil, dust, dirt, and has even been 
found in the atmosphere. The disease is by no means a frequent 
one, and is very rarely found in any but the environment of dirty 
and ignorant people, or in institutions. 

There are no known characteristic lesions, although spinal 
hyperemia has been found in a number of post-mortem examina- 
tions. Death seems to occur from the action of a poison or 
poisons which do not create organic changes. These poisons may 
be albuminous or non-albuminous. Martin believes that the main 
one is a proteolytic ferment, and that the albumoses are derived 
from its action. The various poisons so far obtained, such as 
tetanin, tetanotoxine, spasmodin, and spasmotoxine, are at present 
matters of further investigation. 

The symptoms begin within an uncertain period after inocula- 
tion. The time, as usually stated, is a few hours or days. But 
experiments demonstrate that the bacillus requires several days 
to grow, and therefore to cause symptoms. Sometimes the effects 
show themselves only after the lapse of one or two weeks. Mus- 



THE SPECIFIC INFECTIOUS DISEASES 477 

cular rigidity is first noticed, especially when the patient is an 
infant and attempts to nurse. The spasms at first are transitory, 
but gradually they become severer and more frequent, until the 
intervals between them are comparatively few and small. When 
the disorder is at its height the jaws are set in a state of trismus, 
the back is hard and rigid, the amis and legs are extended, the 
thumbs turned in, and the hands closed. The face is set and has 
a pouting expression, the throat muscles are in such a spasm that 
deglutition and even breathing are difficult; in some cases the 
respiratory disability is increased by spasm of the diaphragm and 
the muscles of the thorax. The child is able to give no more 
than a faint, peevish cry, and rapidly becomes exhausted. The 
pulse is weak, the temperature irregular, the respiration shallow. 
At intervals he becomes bathed in a profuse sweat ; and all through 
the disease there may be gastro-intestinal disorders that are very 
obstinate. 

Treatment. — The most valuable factor is avoidance of infec- 
tion by strict asepsis in the care of the new-born, and in older 
children of wounds and denuded surfaces. As soon as a diagnosis 
is made, the specific antitoxine should be injected in large quantities, 
and often enough to give relief. The drugs which were formerly 
employed are depressants and antispasmodics, such as chloral, 
bromides, and calabar bean. To them we may advantageously add 
antipyrine. All of them must be administered in large amounts 
and at frequent intervals. If the wound through which the inocu- 
lation took place is known and easily accessible, it should be freely 
opened, and thoroughly irrigated with a strong bichloride of mer- 
cury solution. Under all conditions absolute rest and quiet are 
essential. These are required not only for the child's comfort, but 
also for his safety. A comparatively slight amount of handling, 
motion, or even noise may be the immediate cause of a convulsion, 
or at any rate of a spastic condition that is not easily resolved. 
Stimulation should be liberal and unceasing. 

On account of the spasm of jaws and throat, the child may 
be unable to drink ; we can obviate this difficulty to some extent 
by passing a catheter through the nose into the stomach by which 
gavage may be practised. 

Prognosis. — The disease occurs less frequently than in former 
times, and its mortality has been reduced. Some observers report 
a saving of about twenty-five per cent of the cases, in place of 



478 THE MEDICAL DISEASES OF CHILDHOOD 

five per cent that formerly survived. The statistics are, however, 
unreliable on account of the comparatively small number of cases 
that come under our notice. 



Epidemic Cerebrospinal Meningitis 

This is an acute infectious fever, which has been called spotted 
fever, epidemic meningitis, malignant purpuric fever, and cold 
plague. It attacks both human beings and animals in epidemics 
and sporadic cases. The epidemics have appeared more definitely 
or have been better recognized in the United States than in 
Europe ; at all events we seem to meet it in America more widely 
than abroad. 

Causes. — Although the causative micro-organism was described 
by Weichselbaum in 1887, the scientific world paid very little 
attention to his communication. Authors continued to speak of 
an unknown aetiology, or, doubting the specificity of the disease, 
mentioned it as an acute meningitis. In 1895 Jaeger, followed by 
Councilman and others, confirmed the findings of Weichselbaum, 
and in 1899 Osier, in his Cavendish Lecture, added still further 
proof that the disease was dependent upon infection by the Diplo- 
coccus intracellularis meningitidis. It is found in the cerebro- 
spinal fluid, the blood, and sometimes in various parts of the body, 
and may be recognized on cover-slips and in cultures. It may 
occur alone, but frequently is associated with other micro- 
organisms, such as streptococci and pneumococcus. In other 
cases although Diplococcus intracellularis alone was found in the 
meninges, the pneumococcus, staphylococci, streptococci, Bacillus 
coli commune, and Bacillus lactis serogenes may be found in other 
situations. 

Lesions. — The pia mater of the spinal cord and the convexity 
and base of the brain is the part directly affected. The tissue is con- 
gested, the vessels are dilated, and about them there is an infiltration 
of leucocytes. The pia mater of both brain and cord are infiltrated 
with a variable amount of serum, fibrin, and pus whose location is 
determined in part by the location of the affected area, and in 
part by the patient's position. The amount of the exudate 
varies within wide limits : it may be so small that the unas- 
sisted eye is unable to discover it, or, on the other hand, may be 
so large that it distends the ventricles. A similar fluid may be 



THE SPECIFIC INFECTIOUS DISEASES 



479 



found in the central canal of the cord, in some cases being more 
or less deeply stained by small haemorrhages. Such haemorrhages 
may likewise take place in various parts of the pia mater and sub- 
jacent tissue. Long continued cases may present a lardaceous or 
amyloid degeneration of the pia mater. In some instances there 
may be purulent arthritides, multiple abscesses, hypostatic conges- 
tion of the lungs, parenchymatous degeneration of the kidneys, 
spleen, liver, and heart, subserous haemorrhages of the endocar- 




Fig. 95. — Normal Cerebral Meninges. X 60. 

dium, and hyperplasia of the intestinal lymph-nodes. A petechial 
eruption is one of the common features of the disease. 

Symptoms. — As a rule the disease sets in suddenly, and very 
commonly with a chill. There may have been no prodromal signs 
at all, or the child may have complained of feeling depressed and 
weak. The first sign that is characteristic is a very intense sort 
of headache, located in any part of the head, which produces a 
prostrating effect. If the child tries to walk, he is dizzy and 
staggers about. From the head the pain extends to the neck and 
down the spine ; on account of it the head may be held stiffly or 
be retracted. The fever sets in with a sudden impulse and may 
run high ; the eyes are dull, the pupils small, and the irritability is 



480 THE MEDICAL DISEASES OF CHILDHOOD 

marked. These symptoms may, in the mild form, constitute the 
whole picture ; occasionally the abortive form occurs, in which 
there is no more than a beginning of the symptomatic course. 
These instances are somewhat rare, and are apt to be confused 
with cases of gastritis which are characterized by marked nervous 
and cerebral symptoms. In the severer cases the ordinary symp- 
toms progress to a more radical development. In such an event, 
there will, in all likelihood, be vomiting; in some cases this is 
both violent and obstinate ; the restlessness gives way to delirium 



/ 




Fig. 96. — Epidemic Cerebrospinal Meningitis. X 30. 

which may at any time change into coma. There may be a series 
of alternations between restlessness and delirium, delirium and 
mania, finally resolving into a comatose state; or the rigidity of 
the neck may change to opisthotonos varied by convulsions. The 
eyes are apt to, have a dull and fixed expression, and if there is 
much effusion strabismus is common. The rapid development of 
such nervous symptoms is generally of grave import. 

The pain in the head, coupled with the fairly constant photo- 
phobia, causes a puckering of the eyebrows and forehead, which 
often assumes the appearance of muscular spasm. It is frequently 



THE SPECIFIC INFECTIOUS DISEASES 481 

associated with twitching of the extremities. Kernig's sign may 
almost regularly be found, if it is carefully sought. To obtain 
this, the patient must be put in the sitting position, and one should 
try to extend the leg upon the thigh. One will then find that the 
flexors contract, and thus prevent the attempt to straighten the 
leg. Another method can be used while the patient is lying 
down : the thigh should be flexed upon the abdomen ; if one then 
attempts to extend the leg, the flexors again contract, and leave 
the knee at a right angle. The tendon reflexes may be increased, 
decreased, or absent. Constipation is a fairly regular symptom, 
and occasionally it resists the action of really strong cathartics. 
If it is neglected, one may expect a gradual development of gastric 
and intestinal disorders. In some cases one of various rashes may 
appear : they may be petechias, herpes of the face and lips, ery- 
thema, urticaria, and less frequently eruptions that resemble those 
of measles, scarlet or enteric fever. In some severe cases there 
may be cutaneous hemorrhages of small extent, which may occur 
on mucous membranes, and in the viscera as well as on the 
skin. 

With these regular symptoms there may be complicating dis- 
orders of the lungs, heart, pericardium, stomach, intestines, liver, 
and kidneys. These inflammations vary in kind and degree ac- 
cording to the circumstances of each case. In addition there may 
be diseases of the eye, such as iritis, keratitis, and choroiditis, of 
the ear, and of the joints. After some exhausting attacks a chronic 
hydrocephalus may remain. 

Treatment. — At the first symptoms, the patient should be put 
to bed in a quiet, dark, and well- ventilated room. The gastro- 
intestinal canal should be emptied by means of small and repeated 
doses of calomel followed by a saline. Ice bags should be applied 
to the head, and, if possible, to the spine as well. It has been 
customary to prescribe ergot, with the idea of diminishing the 
cerebral l^peraemia ; but at most the value of the drug is ex- 
tremely doubtful. The pain, twitchings, and rigidity may be fairly 
well controlled by antipyrine in doses of 0.06 gramme (1 grain) for 
each year of age, every four, three, or two hours, in conjunction 
with a cardiac stimulant. This remedy will be found much more 
effective than the bromides, phenacetine, or the salicylates. Where 
it is insufficient, one may use opium to good advantage. 

A comparatively recent procedure, that is destined to be widely 
2i 



482 THE MEDICAL DISEASES OF CHILDHOOD 

used in this and other cerebrospinal disorders, is Quincke's lumbar 
puncture. The operation, which has for the most part been used 
for diagnostic purposes, has been said to have therapeutic possibili- 
ties as well. If strict antiseptic precautions are taken, there is 
very little danger incurred in performing it. The puncture may 
be made between the third and fourth, or fourth and fifth lumbar 
vertebrae, and an amount of fluid may be removed which varies 
according to the pressure in the central canal ; as much as sixty 
grammes or even more has been abstracted, with amelioration of 
fever and symptoms of pressure. Another surgical method, which 
will, as some writers believe, be used with advantage, is the 
removal of the spinous process of a lumbar vertebra, followed by 
a thorough irrigation and washing of the spinal canal. But such 
treatment would be so radical, would expose the patient to such 
great dangers, and necessarily presents so many objections, that 
its value is problematical. 

In other respects the treatment is symptomatic, and the various 
complications call for their respective measures. 

Prognosis. — It is hard to judge of the outcome of any case of 
cerebro-spinal meningitis, and the mortality in the various epi- 
demics varies within wide limits. All that one can state is a few 
general observations : as a rule, the younger the child, the greater 
is the likelihood of death. The severe cases are most apt to die at 
the outset, the mild ones toward the end of the disease. Cases 
which begin with a brilliantly aggressive set of symptoms are 
more to be dreaded than those that start in a gradual fashion, and 
with a steady development of prodromata. 

Differential Diagnosis. — The main points for diagnosis are the 
existence of an epidemic, the development of cerebral symptoms, 
and most important of all, the finding of the specific germ in the 
cerebro-spinal fluid. One must keep in mind that the repeated 
examination by both microscope and cover-slip may be necessary. 
Confusion with the acute exanthemata may be avoided by exclud- 
ing their characteristic signs, At times it may be difficult to ex- 
clude pneumonia and typhoid fever, but here again not only the 
physical signs, but also a bacteriological examination, will decide 
the matter with certainty. Kernig's sign may be of considerable 
help in showing the existence of disease of the spinal meninges. 
There may be considerable difficulty in diagnosticating epidemic 
cerebro-spinal meningitis from tubercular meningitis ; in the former 



THE SPECIFIC INFECTIOUS DISEASES 483 

the attack is apt to be more acute, more startling in its manifesta- 
tions, and more painful than in the latter. In addition, in tuber- 
cular meningitis one commonly may obtain a history of tuberculosis, 
tubercular involvement of other areas, and actual or recent physi- 
cal deterioration from exhausting disease. In some cases the 
diagnosis can be made only after extended observation. 



CHAPTER XXI 

THE SPECIFIC INFECTIOUS DISEASES (continued) 

Tuberculosis 

Tuberculosis is an infective fever characterized by a specific 
setiology, commonly a sub-acute or chronic course, the production 
of toxines whose results are an irregular febrile movement, and the 
formation of new and easily degenerating tissue called tubercle 
which may become so much further weakened as to deserve the 
name caseous. The disease may attack any part of the bod}^ 
although some are frequently and others rarely involved. Wher- 
ever the characteristic changes occur, there one usually is able to 
find the specific micro-organism, the bacillus of Koch (1882). 

The disease may occur at any age, and has even been found in 
the foetus. Nevertheless, one may not say that it is hereditary. 
Tuberculosis of the placenta is veiy apt to result in infection of 
the unborn child, since the physiology of the circulation makes im- 
munity improbable or impossible. On the other hand, a localized 
tubercular inflammation in any other part of the body does not 
by any means necessarily result in specific contamination of the 
foetus, so that finally one must put the heredity of this disease in 
the same class as that of various acute infectious diseases, such as 
measles and scarlet fever, which may occur in intra-uterine life, but 
which are certainly not hereditary. The idea of heredity involves 
a change in germ-plasm according to some definite character in the 
body, and the inevitable transmission to the offspring of this changed 
germ-plasm and definite character. In tuberculosis this does not 
necessarily result. It is not at all hard to find cases of tubercu- 
lous parents whose children, especially if they were removed from 
the parental environments, developed into the ordinary degree of 
health and strength. And on the other hand every one is familiar 
with instances of children, whose heredity is clear, who under cir- 
cumstances of poor local or general nutrition and in unfavorable 
surroundings quickly succumbed to the disease. The most that 

484 



THE SPECIFIC INFECTIOUS DISEASES 485 

one may say in regard to the transmissibility of tuberculosis is that 
its presence so vitiates the patient's power of resistance, faculty of 
assimilation, and potentiality of development that his body becomes 
debased below its normal standard, and that his possibility of pro- 
creating fully vigorous offspring is thereby reduced. In addition, 
this weakness in his progeny seems to take the form of an especial 
susceptibility to attacks of the bacillus of tuberculosis. Far- 
ther than this one cannot logically go. Nor indeed may this ac- 
cessibility be derived only from such a specific heredity ; on the 
contrary, this susceptibility to invasion follows almost any condi- 
tion of depression, such as what often follows measles, epidemic 
influenza, whooping-cough, enteric fever, and pyogenic processes. 
In other cases a similar result may be brought about by unwise 
or unfavorable methods of life, such as improper food, improper 
clothes, exercise, and general environmental conditions. This re- 
ceptivity may be not only general but also local, for the same prin- 
ciple of lessened resistance is present in both. Thus an injured 
joint, a diseased lung, an overburdened and exhausted lymphatic 
system are all capable of acting as the starting-point for a tubercu- 
lar process whose activity in spreading depends again upon the 
degree of vitality in the related parts. This idea of deficient resist- 
ance is at the base of processes attached to tubercular inflamma- 
tions, but different from them. In this way other micro-organisms, 
such as streptococci, may be found in an active connection with the 
tubercle bacillus, and in all likelihood the relation in time between 
them is merely fortuitious, so that either may precede or follow 
the other. At any rate, a tubercular inflammation complicated 
by the action of additional micro-organisms must naturally give 
severer symptoms than otherwise would be felt. 

The location of the primary tubercular lesion depends upon 
local conditions, although not all parts of the body are equally 
open to it. Wounds and abrasions of the skin, which one would 
suppose to be frequently affected, are very rarely involved. Occa- 
sionally in hospital practice such an inoculation is seen in circum- 
cisions performed by a tuberculous mohel ; but it should be regarded 
as something of a curiosity. The commonest method is by way of 
an injured, irritated, or inflamed mucous membrane. The converse 
idea is likewise true : that normal mucous membranes are one of 
the best defences against the disease. This membrane throughout 
the respiratory track is the favorite site of a beginning lesion, 



486 THE MEDICAL DISEASES OF CHILDHOOD 

partly because of the ease of infection through the germ-laden in- 
spired air, partly on account of the mucus in which the bacilli may 
thrive, and partly because there is no distinctly acid secretion or 
other sufficient agent to stop their growth. The frequency with 
which disorders of the respiratory track occur is another favorable 
condition for their flourishing, and in this light, attacks of rhinitis, 
hypertrophy of the pharyngeal tonsil, and inflammations of the 
throat and bronchi assume a greater importance than their imme- 
diate action would otherwise warrant. Poor ventilation, impure 
air, and a lack of cleanliness of the nose and mouth have a certain 
share in inviting these attacks. 

The mucous membrane and glands of the gastro-intestinal 
track are less subject to invasion ; especially is the stomach 
rarely involved, doubtless on account of the acid character of its 
secretions, although milk which forms so large a part of the 
child's dietary is an excellent vehicle for carrying the tubercular 
bacillus. The intestines are affected for the most part by bacilli 
in the food, or by extension of the disease through the lymphatic 
channels. In this region one may at times find the phenomenon 
of a transmigration of the bacilli through a normal mucous mem- 
brane into the mesenteric glands, thus producing the condition 
called tabes mesenterica. In all likelihood a similar process is 
responsible for some cases of lupus of the face, where the micro- 
organisms pass through the mucous membrane of the mouth and 
nose, and finally produce the characteristic lesions in the skin. 

The main highway along which the infection passes is the 
chains of lymphatic glands ; and these are involved in proportion 
to the frequency of infection in the parts with which they are 
connected. This is the reason why the tubercular adenitis in a child 
has such an important bearing upon our prognosis of his disease, 
excepting in those cases where the process is plainly confined to 
the glands alone. Of the superficial glands, those of the neck are 
the oftenest involved; with much less frequency those of the 
axilla and the groin are implicated. Of the deeper glands, those 
about the trachea and bronchi are the ones commonly enlarged, 
although clinically we are able to recognize their existence only 
when they give rise to pressure effects. All these various phases 
of adenitis are more commonly encountered in young children than 
in adults. 

Lesions. — The changes which occur in tuberculosis are the de- 



THE SPECIFIC INFECTIOUS DISEASES 487 

struction of fixed tissue, the production of miliary tubercles, of dif- 
fuse inflammation, caseation, and calcification of the products of 
inflammation. When other pathogenic bacteria are present, the 
ordinary degenerative processes attending their activity may be 
expected. Tubercle tissue may occur in small, miliary forms 
which remain discrete, or coalesce into larger masses. It con- 
sists of gray granulation tissue, with small or giant cells held 
in a fine network of basement substance. Around the affected 
area a large number of leucocytes cluster, which are most plen- 
tiful where the specific lesions follow the infliction of an injury. 
The tubercle tissue is poorly supplied with vessels, and as sepa- 
rate areas unite, a correspondingly large section becomes cut off 
from the circulation. This weak and vicious tissue is then said 
to become cheesy, and finally as the last step in this retrogressive 
action breaks down. At and beyond the margin a variable amount 
of fibrin-infiltration may take place ; and as it tends to limit the 
spread of the local lesions, it really is a step in the direction of 
health. In other cases, where the disease is decidedly chronic in its 
course, the bacilli become coated with a material which becomes 
infiltrated with calcareous matter composed in the main of calcium 
phosphate. This process of calcification may spread until it 
replaces the tubercular tissue, kills off the bacilli, and puts an end 
to the disease. While these phenomena are characteristic of the 
disease, nevertheless the various parts of the body have individual 
peculiarities of involvement that are important enough to be 
known separately. In children the lungs, after the glands, bones, 
and joints, are the parts most frequently diseased, both primarily 
and secondarily, and the younger the child the more likely are 
they to be infected. The disease attacks by preference the upper 
rather than the lower parts of the lungs. After them, the brain 
and the meninges are the parts which are implicated in the next 
degree of frequency, while tuberculosis of other portions of the 
body is considerably more rare. 

In the lungs the disease may occur as part of a general tuber- 
culosis or as a distinct localization. In the first division the lungs, 
as well as the other viscera, are the seat of a miliary infection. These 
deposits may be found in large or small quantities, although in chil- 
dren the tendency is more in the direction of large masses than in 
adults ; also a part or the whole of the lungs may be involved. 
The miliary tubercles may occur in various forms and locations : 



488 



THE MEDICAL DISEASES OF CHILDHOOD 



the walls of an air-space may be infiltrated and the cavity filled 
with tubercle or fibrin and pus ; or the tubercle tissue may en- 
tirely replace the lung tissue ; or the tubercles may infiltrate the 
walls of the small bronchioles on one or more sides and for a vari- 
able extent. The inflammation may extend to the near-by air- 
spaces, the walls of which may be infiltrated and the cavities filled 
with fibrin and pus ; or large masses may occur, formed by the 
infiltration of the walls of larger bronchioles, each of which has its 
surrounding area of infiltrated air-vesicles. 




Fig. 97. —Acute Miliary Tuberculosis of the Lung, x 30. 



Instead of the acute course, the lesions may assume a sub-acute 
type. The disease is generally localized in the upper lobes, from 
which it may or may not extend. The walls of the small bronchi- 
oles and the adjacent air-spaces may be infiltrated, and in the 
surrounding area there may be the ordinary lesions of simple 
inflammation of the bronchi. In some cases the process may 
become chronic : then the tubercle tissue is harder than in the pre- 
liminary forms, and continues so until it breaks down into caseation. 
Its location is much the same as in the sub-acute course, 
although the duration of the process permits of indefinitely great 
extensions through the lungs or the rest of the body. Thus the 



THE SPECIFIC INFECTIOUS DISEASES 



489 



pleura, the larynx, the glands of the mediastinum and mesentery, 
may become involved to any extent. In connection with this 
there is commonly a chronic inflammation of the bronchi and the 
lung tissue, with the accompaniment of conditions that charac- 
terize long continued pulmonary changes, such as the formation 
of connective tissue, emphysema, and bronchiectasis. 

Local tubercular disease (acute or chronic pulmonary tuber- 
culosis) is one of the commonest forms that the disorder assumes 
in children. In the acute form, besides the tubercular inflamma- 





Fig. 98. — Chronic Tubercular Pneumonia with Cheesy Defeneration. X 30. 



tion, there are the regular changes of an ordinary broncho-pneu- 
monia in one or more spots or lobes. This inflammation may be 
irregular in its distribution, the bronchitis being especially marked. 
In other cases there is besides the tubercular lesions a distinct 
pneumonia characterized by diffuse consolidation, with the ordinary 
phenomena of fibrin, pus, and broken-down epithelium filling the 
air-spaces. Where the pyogenic processes are far advanced, there 
may be areas of coagulation necrosis in all degrees of degeneration. 
In addition the pulmonary tissues may fall into the same patholog- 
ical complications and sequels that attend a non-tubercular inflam- 
mation of them. For these conditions must be regarded as mixed 



490 



THE MEDICAL DISEASES OF CHILDHOOD 



infections in which the tubercular elements may develop side by 
side and with the several peculiarities that belong to each. 

An acute pulmonary tuberculosis may gradually take on a 
chronic form, or the inflammation may from the first be of a 
chronic nature. The essential character of the disease is that of 
a tubercular broncho-pneumonia with choking up of the air-spaces 
by means of degenerated epithelium, or fibrin and pus, which have 
a tendency to caseous degeneration ; in some cases there is a 
marked disposition to the formation of connective tissue in the 




"» 



Fig. 99. — Chronic Pulmonary Tuberculosis with Conservative Fibrosis. X 30. 




air- vesicles, in their walls, in the bronchioles, and the septa. The 
sclerotic process is irregular, and consequently gives rise to various 
deformities. In the bronchi, in conjunction with the chronic 
catarrhal inflammation, there may be a cellular infiltration that 
weakens the bronchial walls, and thus causes dilatation ; the walls 
may be riddled with tubercle tissue that inclines to caseation. As 
a result of the two processes cavities of various sizes may be formed. 
The pleura is not often affected primarily, but merely as an 
extension of the pulmonary lesions. The first changes are apt to 
be a miliary tuberculosis on the pulmonary aspect of the mem- 



THE -SPECIFIC INFECTIOUS DISEASES 



491 



brane, followed by the development of adhesions and the deposi- 
tion of connective tissue. Fluid may then be formed in the 
cavities, which by contamination with tubercle bacilli, streptococci, 
or staphylococci, becomes purulent. 

The glands are among the first parts to show the effects of 
infection, not necessarily because the bacilli have a preference for 
them, but rather on account of their function of filtering out waste 
and foreign matter. Usually the tissues with which they are 
connected receive the infection, and then pass it on to them ; 




Fig. 100. — Tuberculosis of Lymph-Node. X 30. 



it is possible, however, for the bacillus to pass through uninjured 
mucous membrane, and find a lodgement in adjacent glandular 
structure. As an instance of the first process one may mention the 
adenitis in the neck following invasion through the pharynx, or 
about the roots of carious teeth, or the mediastinal adenitis following 
pulmonary infection; an example of the second process, as noticed 
above, is occasionally seen in the mesenteric glands, or in the 
occurrence of some cases of lupus on the face and about or near 
the nose. 

The cervical glands are the ones most commonly involved; 



492 THE MEDICAL DISEASES OF CHILDHOOD 

those about the trachea and bronchi are not so often plainly 
implicated through marked symptoms, but nevertheless pulmonary 
lesions regularly affect them, if only slightly. Many times they 
alone are attacked and remain the only seat of infection, even 
though they give no symptoms. Among the last named struc- 
tures are the anterior and posterior mediastinal, the cardiac, the 
intercostal, and sternal groups. The first influence causes them 
to enlarge, and small miliary spots or areas appear which tend 
to unite, forming the location of caseation. This latter process 




Fig. 101. — Tuberculosis of the Kidney. X 115. 

may be slow or rapid. In the first case the individual glands 
are small, although the union of many of them may produce a 
large mass ; their capsules are thickened, hard, and fibrous, and 
do not readily become attached to the surrounding tissue or the 
skin. In some cases fibrosis may extend so far as to change the 
whole structure of the gland, with the attendant result of decreas- 
ing the number of bacilli present. In other cases the cheesy 
degeneration may undergo a process of calcification that is essen- 
tially conservative. Where the pathological changes are more 
rapid, as is common, they spread from the centre of the gland in 



THE SPECIFIC INFECTIOUS DISEASES 



493 



all directions ; all the surrounding and adjacent tissues are influ- 
enced accordingly, and consequently become matted together. 
The skin in turn may finally become involved, and at the point 
of attachment the subsequent abscess will break. 

In the bones similar processes occur, having their location in and 
near the epiphyses of the long bones and in the centre of the short 
bones. The cancellous tissue is the part first to be affected, and 
the process goes through the stages of congestion, cell-infiltration, 
and caseation ; frequently the new and debased tissue breaks 




Fig. 102. — Miliary Tuberculosis of Liver. X 60. 

down, and is followed by suppuration. This process may stop 
here and encapsulation of the broken-down tissue may ensue, or 
it may go on and involve both bone and joint. In this way 
complete destruction of the part may take place, until the abscess 
finds an outlet either spontaneously or by operation. In either 
case, if the patient's vitalhVy is good enough, a conservative and 
reparative growth of bone begins, which may to a fair extent 
replace the destroyed parts by new osseous tissue even in the 
joint. Anchylosis naturally results. 

The kidneys are not often affected in childhood ; but when in- 
fection does occur, it may be in the form of miliary tubercles, or 



494 



THE MEDICAL DISEASES OF CHILDHOOD 



larger cheesy areas. Either form may be multiple, and the sepa- 
rate patches may coalesce so that large masses of the organs 
become changed. Where the inflammation has not extended to 
a marked extent, the lesions may be shut off by a gradual fibrosis 
and calcification. This result may occur in tubercular disease of the 
suprarenal capsules, as was demonstrated to me in the autopsy on a 
boy of nine years. The whole organ, including the capsule, was 
shrunken and somewhat irregular in form. There were small areas 
of fibrous degeneration, and evidences of tubercular infiltration. 




Fig. 103. — Acute Miliary Tuberculosis of Spleeu. x 60. 

In the liver and spleen the infection occurs in miliary granu- 
lations. It is only in unusual cases that fairly large caseous areas 
are seen, although in advanced cases several miliary tubercles may 
coalesce, and thus form a larger growth. The disease appears in 
these organs as the result of extension rather than primary loca- 
tion. The size of the viscera may be increased, if there is a mixed 
infection with the production of pus, or if there is sufficient 
development of tubercles to increase by their bulk the ordinary 
dimensions. Such growth may oftener be looked for in children 
than in adults. In chronic cases amyloid degeneration of both 
organs may be expected. 



THE SPECIFIC INFECTIOUS DISEASES 



495 



The stomach is involved in the rarest cases only, on account, 
as stated before, of the acid reaction of its secretions. When such 
involvement does occur, it is in the last stages of a practically uni- 
versal infection. The intestines, on the other hand, are much oftener 
contaminated ; here, again, the infection is generally secondary to 
that of the lungs or brain. The lesions are oftenest located in the 
small intestine, but in cases of very general distribution they may 
be in the large as well as the small gut. The disease usually 
begins with the formation of miliary nodules, which coalesce and 




Fig. 101. — Tubercular Ulcer of Ileum. X 30. 



so form a much larger one. This finally becomes caseous, breaks 
down, and forms a superficial ulcer which extends around a part 
or even the whole circumference of the intestine. Its surface is 
rough, its edges are undermined, its base is infiltrated. It may be 
of any depth, and so involve only the mucous coat, or the others as 
well, even the serous. In such cases perforation may result ; but 
it does not necessarily predicate the development of a general peri- 
tonitis, since the ulcer in its formation gives rise to a certain amount 
of plastic inflammation, which mats together adjacent parts and so 
prevents infection of the peritoneal cavity. The connected mesen- 



496 THE MEDICAL DISEASES OF CHILDHOOD 

teric glands are always affected, and the amount of disorder is 
proportional to the extent and severity of the intestinal lesions. 
They undergo the same changes described above in the account 
of other glands throughout the body. Like them, also, they may 
become subject to fibrous or calcareous degeneration, or finally 
break down into a purulent condition. Extreme enlargement may 
cause pressure symptoms ; but this is rarely seen. 

The spread of the disease from the intestines to the peritonaeum 
is always possible, especially in older children. In infants, tuber- 




Fig. 105. — Tubercular Meningitis. X 60. 

cular peritonitis is not frequent by any means, nor is it common to 
see a primary tubercular peritonitis at any age. When the dis- 
order does occur, it resembles the process in the gut. It usually 
begins as miliary granulations, which as they increase in number 
and size may coalesce and form larger masses. There may then 
be a cheesy softening, which on the one hand may be cut off and 
repaired by a more or less active fibrosis, or on the other may 
soften and break down into ulcers whose characteristics strongly 
resemble those of the intestines. As in other serous cavities, there 
may be large quantities of serum, with or without the addition 
of pus. 



THE SPECIFIC INFECTIOUS DISEASES 497 

In the brain tuberculosis occurs fairly often in children, especially 
between the ages of two and eight years. There are miliary granu- 
lations and small nodules which rapidly become soft and caseous. 
Around each is a small area of encephalitis ; the older ones, how- 
ever, may have a zone of fibrous tissue about them. These bodies 
may occur in any part of the brain, but in children the favorite 
seat is at the base. In the meninges the pia mater may be studded 
with miliary nodules, as in the brain. They may be seen strung 
out along the vessels which enter the brain, especially those which 




Fig. 106. — Tubercular Pericarditis. X 30. 

lead into the fissure of Sylvius. Likewise one may see them in 
the interpeduncular space, and thence in the membrane of the 
transverse fissure. The lateral ventricles are generally filled with 
serum, or serum and pus, the quantity of which increases with the 
duration of the sickness. The pressure may be great enough to 
weaken and flatten the ventricular walls, and in infants to make 
the fontanelles project beyond their usual plane. These infections 
of the brain and meninges, and among them may be included simi- 
lar disorders of the cord, occur as extensions from tuberculous 
disease of the lungs, bones, joints, or intestines. 

In cases where the lesions are widely disseminated other organs, 



498 THE MEDICAL DISEASES OF CHILDHOOD 

such as the heart, pericardium, the choroid of the eye, the testicle, 
the Fallopian tubes, ovaries, and uterus may become involved. 
The conditions are not only rare, but have nothing peculiar to 
children in them. Even in the skin, where a chronic tuberculosis 
in the form of lupus sometimes affects children, there are no new- 
factors outside of tissue necrosis and superficial ulceration. A 
noteworthy feature is the lack of fibrosis and calcification, except- 
ing the amount of fibrous tissue which is produced in the scars. 

Symptoms. — Tuberculosis has an incubation period, as we 
know from inoculation experiments ; but in actual practice we 
are unable to fix and define it. The disease has certain pecul- 
iarities that mark it off from the other infectious fevers, such as 
its common tendency to chronicity, and its faculty of producing 
organic lesions of a peculiar kind in any part or organ of the 
body. The temperature is atypical, and varies with the severity 
and location of the infection ; as a rule, however, the fever is not 
very great, and may at times be so slight as to escape notice. The 
disease is characterized by progressive loss of flesh and strength 
that is most marked in the last stages, by night sweats that begin 
toward the end of the night when the temperature falls, by 
anaemia, intestinal disorders, and occasionally by amyloid degen- 
eration of the liver, spleen, and intestines. In the acute general 
infection, often seen in infants, the disease appears in its purest 
type. Every organ may be involved, and nevertheless no one 
organ may give predominant symptoms. The cough is often not 
impressive, the gastrointestinal disorders may be transitory, the 
spleen may not be enlarged, or at most it is only slightly enlarged, 
and the cerebral symptoms are commonly of secondary importance. 
At the same time there is a marked and rapid loss of health 
which has a wide range of objective symptoms.. These vary con- 
siderably as one organ or another feels the attack most acutely. 
Lack of appetite, vomiting, and constipation or diarrhoea are com- 
mon, even if not impressive. In most cases the child is unable 
to digest and assimilate his food, and in spite of the most careful 
regulation and modification of his diet his condition does not 
improve. He is apt to be peevish and fretful, his sleep is dis- 
turbed, and as day after day passes by he looks more and more 
emaciated. Gradually a general adenitis may become evident, 
in some cases causing pressure symptoms. There may be sudden 
exacerbations of local disabilities, which progressively become 



THE SPECIFIC INFECTIOUS DISEASES 



499 



more serious. Every organ may be attacked, even before the 
symptoms indicate the invasion. The whole course of the dis- 
ease represents a steady and comparatively rapid deterioration of 
the body and its functions ; and day after day the patient becomes 
weaker, sicker, and less capable of efficient, physiological activity. 
An acute course gives the most plainly marked signs, doubtless on 
account of the rapidity of absorbing the toxic products of the 
disease; a chronic course may give comparatively fewer signs, 
because the lesions are very gradual in their development and 
finally become shut in by the processes of fibrosis and calcification 
so that absorption is prevented. 

Such an acute course characterizes the miliary tuberculosis of 
infants; and at times one may have difficulty in distinguishing it 
from marasmus, or any other wasting disease. Especially may it 
be hard to classify the symptoms properly if an added infection 
or an added disorder occurs. Under such circumstances one may 
need the observation of a few days to eliminate conflicting factors 
from the picture. The same idea occurs again in older children in 
whom, on account of their greater vitality, the disease takes a 
longer time to cause death. Here the long drawn out malaise, 
the increasing weakness, the possibility of an enlarged spleen, the 
possible disturbances of the intestines, and finally the supervention 
of a typhoidal condition, all go to suggest enteric fever. 

When tuberculosis becomes localized in the lungs we have a 
combination of the general features of the disease plus the special 
form of the pulmonary disorder. Thus, a child who has tubercu- 
losis in any other part or parts of the body, who has been suffer- 
ing with other pulmonary or exhausting complaints, easily falls 
into a tubercular broncho-pneumonia, which nevertheless is not 
markedly different in its main signs from the simple broncho- 
pneumonia. The length of the sickness is a point of some diagnos- 
tic importance, since instead of the ordinary recovery after a few 
days, the child continues very sick for two, three, or four weeks, 
or even more. Whether the case is rapid or protracted makes 
no great difference in the general symptomSo The temperature 
may not be as high as in the simple form, but as the disease pro- 
gresses and the patient's strength fails, its variations become more 
marked. In the morning it may be near normal or subnormal, in 
the evening it may mount as high as 40° C. (104° F.). Toward 
morning, when the fever abates, a cool, clammy sweat breaks out 



500 



THE MEDICAL DISEASES OF CHILDHOOD 



on the patient's chest, legs, or over the whole body. His appetite 
is poor, his power of assimilation defective, the loss of strength 
and flesh progressive. The cough cannot be said to have distinc- 
tive characteristics nor is the localization of the disease, which is 
often in the upper lobes and apices, regular enough to be of use 
in defining the disease. The physical signs are those of the ordi- 
nary broncho-pneumonia, but there may be more dyspnoea and 



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PULSE, RESPIRATION AND TEMPERATURE CHART OF GENERAL MILIARY TUBERCULOSIS 

AGE, 7 YEARS. 
pul8e^_ ________«. respiration _.__ "temperature 

Fig. 107. 



cyanosis than one sees in non -tubercular complaints. In very 
rapid cases symptoms of breaking down of caseous areas may 
possibly appear, but they are not regularly to be expected ; and it 
is yet more exceptional to find hemoptysis. The main reliance in 
diagnosis rests on the general aspect of the case, its history, its 



THE SPECIFIC INFECTIOUS DISEASES 501 

development and course, the involvement of other parts of the 
body, such as the glands, joints, brain, and intestines. The rapid 
cases are apt to be the most obscure ; the prolonged cases, on the 
other hand, involve such large areas of lung tissue, and in all like- 
lihood bring out so many signs in the body, that any doubt is before 
long dispelled. 

A chronic pulmonary tuberculosis is not often seen in very 
young children — ■ largely because they have not the vital resistance 
to allow the process to become chronic. Whether the disease begins 
in a slow, chronic fashion, or is merely an extension of an acute or 
sub-acute attack, makes very little difference in the ultimate result. 
In the first case there may be a greater amount of interstitial tis- 
sues in the lungs than in the second; but the distinction is a 
pathological rather than a clinical one. Every part of the lung 
may be involved in the tubercular process, the caseous nodules 
may break down, and cavities of various size result. These com- 
monly have a central location, doubtless because the extension of 
the disease takes place so often through the bronchial and peri- 
tracheal glands at the base of the lungs. This situation of the 
lesions may postpone an exact diagnosis for some time ; the 
patient will have repeated attacks of acute or sub-acute pulmonary 
disorders, which by their frequency and continued course help to 
show the tubercular element. The general picture is that of a 
lung which steadily becomes more and more diseased, passing 
through successive stages of bronchitis, broncho-pneumonia, and 
abscess formation. The usual course is a succession of acute exac- 
erbations each of which, although followed by a period of improve- 
ment, leaves the lungs in a poorer condition than before it began. 
As the disease progresses, the patient becomes weaker and more 
emaciated, the red blood cells and haemoglobin are decreased, there 
is a marked leucocytosis, his appetite is poor, night sweats increase, 
and concomitant disorders — tubercular or non-tubercular — are 
very apt to appear. Especially are derangements of the gastro- 
intestinal track likely to show themselves, bringing with them an 
exaggeration of the child's weakness. The temperature varies 
according to the changing conditions and complications, the pulse 
likewise varies but has a general tendency to thinness and weak- 
ness, the respiration is rapid and shallow, and as the disease 
becomes worse there may be dyspnoea and some cyanosis. The 
sputum in the older children — for very young children do not 



502 THE MEDICAL DISEASES OF CHILDHOOD 

expectorate — is not abundant and does not become purulent until 
the late stages. On coughing or straining, the patient may com- 
plain of shooting and starting pains in the sides which are in part 
due to exacerbations of pleurisy. 

The physical signs are often unsatisfactory ; and while in many 
respects they resemble those of the adult, nevertheless in others 
they are deceiving. Some advanced cases show little disturbances 
in respiration, and the respiratory movement may be less marked 
on the side which is the more affected than on the other. Consol- 
idated tissue gives a dull but rarely a flat percussion sound. The 
signs of cavity formation are especially deceptive ; where a cavity 
is present we may, possibly on account of its small size and central 
location, not find the ordinary diagnostic symptoms ; while on the 
other hand the most deceiving indications of cavity may be distin- 
guished over a comparatively healthy part near a superficial bron- 
chus or bronchiole. 

Tubercular pleuritis gives no special symptoms by which one 
can readily distinguish it from the non-tubercular. Only in a 
small minority of cases is it empysemic, unless it occurs as a mixed 
infection. It may, however, give signs of an irregularly thickened 
pleura and of few or many adhesions. A pleuritis occurring in a 
tuberculous patient is commonly regarded as tubercular. 

The bronchial and peritracheal glands are frequently affected 
in children, occasionally as a primary disorder, but commonly in 
conjunction with pulmonary tuberculosis. One may take for 
granted that a case of this lung disease involves changes in the 
associated lymph-nodes, even though no symptoms may appear. 
The younger the child, the easier does this involvement occur. 
When symptoms appear, they are in the form of pressure effects 
which may arise from one part or another according to the loca- 
tion of the enlarged glands. Thus the recurrent laryngeal or 
pneumogastric nerves give hoarseness, dyspnoea, and a dry, hack- 
ing, persistent cough in repeated attacks. When the trachea or a 
bronchus is affected, the attacks of dyspnoea come intermittently, 
the head is thrown back in a tonic spasm, and the effort to accom- 
plish inspiration is at times pitiably great. In other instances 
the superior vena cava, the pulmonary artery, or the aorta may be 
impinged upon, giving symptoms of cyanosis, dyspnoea, and per- 
sistent hacking cough. It is also possible for ulceration to take 
place from these glands into the bronchi, trachea, oesophagus, the 



THE SPECIFIC INFECTIOUS DISEASES 



503 



thoracic duct, the vessels mentioned, and the epicardium. When 
the bronchi or trachea are perforated death usually occurs, although 
rarely the pus may be coughed up and the patient thereby relieved. 
Rupture of the vessels is fatal. 

The large size of glandular swellings may complicate the signs 
in the chest to an unfortunate degree. It may give dulness along 
the median line, both front and back ; it may transmit the sounds 
of cavernous and bronchial breathing as well as large and small 
moist rales. The passage of air through a part of the lung may 
be shut off, and a condition of partial collapse be the result. 
These various symptoms are not to be expected unless the swell- 
ing of the glandular tissue is unusually great. 

As far as tubercular disease of the bones is concerned we have 
to do with the first symptoms; for when the location of the 
disease is clearly defined the care of the case should be given to a 
surgeon. These children usually have a tubercular history, and 
often a previous tubercular lesion. The bones of the spine are 
most frequently attacked, and after them in the order of frequency 
are the hip, knee, ankle, elbow, wrist, and shoulder. In tubercu- 
losis of the spine we may find the disease in any of the vertebras. 
We determine the location by the signs of deformity, tenderness, 
and pain, by the muscular spasm of the part, by pains and pres- 
sure effects due to irritation of the spinal nerve roots and their 
distributions, and the manner in which the child mechanically 
disposes his body in order to obtain the greatest ease. Caries in 
the cervical region causes pain and, possibly, deformity in the 
neck ; although this part of the spine is often the latest in show- 
ing full symptoms, nevertheless from the beginning there may be 
tenderness on pressure and some pain on movement. Attention 
to the disease may be first attracted by some degree of periton- 
sillar abscess. In the lower cervical vertebras the deformity occurs 
as a kyphosis, while in the upper bones it projects forward so that 
one may palpate it through the pharynx. 

In the dorsal vertebras the pain is generally located below the 
injured part. The child tries to protect himself as much as 
possible against the shock of movement, and therefore walks and 
carries himself in an awkward fashion. The affected bones, fol- 
lowing the line of least resistance, are pushed backward, forming 
a more or less pronounced kyphosis. In the lumbar bones the 
disease is often the hardest to diagnosticate. The patient keeps 



504 THE MEDICAL DISEASES OF CHILDHOOD 

his spine in a posture of exaggerated rigidity; he complains of 
pains which radiate in the abdomen, the thighs, and the buttocks. 
After these signs appear, one should be prepared to find at any- 
time a psoas abscess ; in fact, tuberculosis of any part of the spine 
is apt to give rise to pus formation, the discharges from which in 
burrowing through the surrounding tissues follow the line of least 
resistance. 

In the hip joint the disease begins in the head of the femur or 
the acetabulum. The child complains of some tenderness on move- 
ment, especially if the motion is at all violent. Little by little the 
tenderness may change to pain ; the joint, on arising in the morn- 
ing, or after being seated for an hour or more, is sore and stiff. 
Gradually this soreness and stiffness become fixed, the patient may 
complain of long continued pain, which, even in the early stages, 
radiates into the knee or the inner aspect of the thigh, although 
the hip joint itself does not seem really painful. At night, in the 
later stages of the disease, he suffers from sudden attacks of 
sharp, spasmodic pains. Inspection will show some atrophy of 
thigh and calf, the gluteal protuberance has but a single fold, and 
is flatter than the normal. Careful examination will show the 
tenderness on pressure and forced movements; the care of the 
case then becomes surgical. 

In the other joints, such as the knee, the ankle, the wrist, and 
fingers, the same general course prevails. There is usually a his- 
tory of tuberculosis, or one or more tubercular foci in other parts 
of the body. Either with or without injury, the joint in question 
becomes stiff, especially after disuse. The stiffness becomes less 
and less transitory, the tenderness gradually turns to pain. The 
joint gradually takes on a fusiform swelling which, on account of 
its lack of heat and redness, has been called a " cold abscess " or 
44 white swelling." The associated muscles become atrophied, the 
inflammation passes from the joint to the soft parts about it, and 
pus may work its way in any direction in or about the joint. The 
diagnosis has by this time become clear, and surgical aid should be 
called to the case. 

In the kidneys and suprarenal capsules tuberculosis gives no 
specific symptoms. There may be pain in the neighborhood, and 
micturition may give a sensation of burning, although the bladder 
and urethra are not affected. If an abscess forms in or about the 
kidney, one may distinguish the tumor on palpation, or pressure 



THE SPECIFIC INFECTIOUS DISEASES 505 

effects may gradually show themselves. The main diagnostic 
points are the presence of tuberculosis in other parts of the body, 
and the rinding of tubercle bacilli in the urine. Likewise in the 
liver and spleen there are no distinguishing marks of tuberculosis 
beyond what one finds in non-tubercular disorders. The liver may 
occasionally be enlarged, and if there are sufficiently prominent 
nodules in the superficial parts of the organs, or in the capsules, 
one may possibly distinguish them on palpation. Otherwise one 
depends upon the conjunction of known tuberculosis in the body 
and the symptoms of hepatic and splenic disease to make a 
diagnosis. 

The stomach is so very rarely tuberculous, and the few cases 
which have occurred have been so far advanced, that there has been 
little opportunity and seemingly no particular value in searching 
for special signs. In the intestines, however, infection is no rare 
occurrence. Outside of the general symptoms of the disease and 
its presence in other parts of the body, there are disorders of the 
gut, confined, for the most part, to the small intestine. The prin- 
cipal of these is a persistent and irregular diarrhoea that at times 
is exceedingly hard to influence. As ulcers are formed there may 
be haemorrhage from them that in unusual cases is so great as to 
be serious. There may be tenderness on pressure, especially when 
the mesenteric glands are much affected. These glands, on deep 
palpation or manipulation, may be felt as single or fused lumps 
along the spine. They, likewise, may be tender, especially 
when the examining hand seeks to move them from their fixed 
attachment. 

Tubercular peritonitis, in at least one of its forms, gives prac- 
tically no symptoms. Where a miliary infection is present the 
disease is often not suspected unless it is sharply localized. In 
the latter instance there are, in some long continued cases, local- 
ized swellings and thickenings of both peritonaeum and omentum ; 
at the same time there are irregular pains in the abdomen, and 
enlargements of the mesenteric glands may manifest themselves. 
Where the miliary tubercles are widely scattered over the whole 
peritoneal membrane, there is a strong likelihood of the transuda- 
tion of a large amount of serum into the cavity. This may set in 
abruptly or in a sub-acute manner; but in either case the main 
symptom is the ascites. The abdominal wall may be so much 
distended that it is hard, tense, thin, and coursed on its surface 



506 



THE MEDICAL DISEASES OF CHILDHOOD 



with dilated veins. A well-marked wave-impulse is easily elicited 
by manipulation. Most cases exhibit irregular abdominal pains, 
irregular alternations of diarrhoea, and vomiting. The systemic 
effects of tuberculosis are coincidently present, and with the known 
existence of the disease in other parts of the body give the surest 
method of diagnosis. In those cases where the tubercular deposits, 
instead of being in the form of miliary granules, are caseous masses, 
degeneration of the new tissue may take place, and a diffuse purulent 
peritonitis results. Naturally this process is slow, and the symp- 
toms develop slowly and irregularly. There are abdominal pain, 
functional derangements of the intestines and sometimes of the 
stomach, and noteworthy loss of flesh and strength. On palpat- 
ing the swollen and sensitive abdomen, one distinguishes a heavy, 
thick consistency, swollen and tender glands, and matted masses 
of intestine and peritoneum. The purulent fluid may be diffused 
over the whole abdomen, or, if there are many adhesions, it may 
be shut off in pockets. One of the favorite locations for such 
encystments is about the umbilicus. In others of the cases of 
caseous deposits the process does not go on to purulent degenera- 
tion, and, instead, the cheesy areas have undergone a conservative 
change into fibrous tissue. The disease then becomes long drawn 
out, and its course alternates between improvements and retro- 
gressions. There are many adhesions, encystments, and matting 
together of intestines and peritoneum. The mesenteric glands 
are enlarged and tender ; and from them and the adhesions various 
pressure effects upon adjacent structures may gradually come into 
action. The amount of effusion is variable, tympanites is marked, 
and pain is considerable. The temperature is irregular, being often 
near normal, but rising easily on slight provocation. There may, 
at various times, be derangements of the intestines, and alterations 
in the general condition of health, according to the fluctuations of 
the disease. 

Tuberculosis in the brain is almost always a secondary condi- 
tion, so that its general nature is understood as soon as symptoms 
appear. The tubercles vary from a minute size to that of a large 
nut or even a small egg. The amount of tissue thus replaced and 
the amount of pressure produced may, on account of the varying 
lesions, not be alike in any two cases. If the neoplasm is large, it 
may produce some effect even upon the exterior shape of the skull, 
or when it projects into the orbit it may cause the eyeball to project. 



THE SPECIFIC INFECTIOUS DISEASES 



507 



The general symptoms are those of cerebral irritation, snch as rest- 
lessness, pain, stupor or delirium, disorders of the cranial nerves, 
motor or sensory paralysis, incoordination, disturbances of vision, 
nausea, and vomiting. By ordinary methods of localization the 
tumor is generally located without difficulty. In the meninges 
tubercular deposits constitute the largest part of the diseases 
there found. In some cases preliminary symptoms, in the way of 



PUL. 


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PULS.E, RESPIRATION AND TEMPERATURE CHART OF TUBERCULAR MENINGITIS, 
FIRST AND SECOND WEEKS. 



PULSE__. 



AGE, 5 YEARS. 

DFQDiDATin>, TEMPERATURE. 

Fig. 108. 



malaise, irritability, general weakness, gastro-intestinal disturb- 
ances, headache, and disturbed sleep, may be present. The 
appearance of gastric disorders as prodromata is both common and 
deceiving ; and one may treat the symptoms for a week or two 
without being convinced of one's mistake. The first thing that 



508 THE MEDICAL DISEASES OF CHILDHOOD 

appears suspicious is the comparatively mild nature of the attack 
and its failure to subside. On the contrary, the child gradually 
becomes worse, the pains in the head grow greater, the temperature 
is irregular, and has a tendency to mount, so that instead of oscil- 
lating from 37.5° to 38.5° C. (99.5° to 101.3° F.) it may attain to 
39° or 39.5° C. (102.2° to 103.1° F.). A noteworthy fact is that 
the pulse rate, unless some complicating disorder interferes, does 
not increase in the same ratio as the temperature ; the respiration 
shows more of a tendency to follow the pulse than the temperature. 
As the disease shows its character more plainly, the child loses his 
brightness and desire to be amused. He becomes more and more 
stupid, and shows an increasing desire to sleep, and in some cases 
it is almost impossible to wake him. The condition now becomes 
steadily worse. The respiration becomes irregular, the eyes dilate 
irregularly and respond poorly to light, and the skin is so sensitive 
that the non-pathognomonic taehe cerebrate and the mark of Trous- 
seau — redness of the skin caused by simple pressure — are com- 
monly seen. The neck becomes rigid, opisthotonos may occur, 
the abdomen may be retracted, and ability to swallow is impaired. 
Bilateral or irregular paralyses may show themselves and remain 
temporarily or permanently. The superficial reflexes are dimin- 
ished, and the deep ones are increased. The eyes show congestion 
of the papillae and often an optic neuritis. The respiration assumes 
the Cheyne-Stokes type, the general prostration increases, the tem- 
perature shows a disposition to rise, convulsions supervene, and 
the child dies in a condition of respiratory and cardiac paralysis. 
The disease may last for a period varying from a few days to sev- 
eral weeks, the shorter periods being characteristic of very young 
children. In some infantile cases the disease runs a chronic course 
with symptoms which point to miliary formation at the base of the 
brain. There are opisthotonos, hydrocephalus, convulsions, gastric 
disturbances, and exaggerated reflexes. The pressure effects are 
naturally in proportion to the extent of the lesions, and the degree 
of ossification in the skull. 

In the other parts of the body the occurrence of tuberculosis 
is almost always secondary; the involvement of these organs is 
not at all mysterious nor is the course of the sickness especially 
peculiar. As an example one may quote tubercular pericarditis, 
a disorder which most often occurs as a part of a general miliary 
tuberculosis. Since it commonly follows disease of the bronchial 



THE SPECIFIC INFECTIOUS DISEASES 509 

and mediastinal glands, it is very apt to be preceded or accompanied 
by pulmonary tuberculosis. Moreover, it occurs in a fairly late 
stage in the process when one or more glands have broken down, 
or ruptured into the pericardium. We consequently find the gen- 
eral features of the systemic process plus those of a purulent or 
sero-fibrinous pericarditis ; or where there is no effusion, the dis- 
ease takes the form of a sub-acute or chronic inflammation with 
the production of a large amount of adhesions. The same general 
idea is true of tuberculosis of the testis, the Fallopian tubes, ovaries, 
and uterus. In the skin the disease is known as lupus vulgaris, 
although a more rational name would be tubercular dermatitis. Its 
favorite location is about the nose, cheeks, and mouth ; but it may 
appear on any part of the skin surface with the exception of the 
palms of the hands, soles of the feet, penis, forehead, and chin. It 
may even extend to the mucous membrane. In the beginning one 
may notice small light brown spots raised above or depressed below 
the surrounding plane of the skin. These spots increase in number 
and size until they form a good-sized patch ; there is an infiltra- 
tion of the skin which helps to create the final picture of a raised 
and irregular periphery and a depressed centre, the color being an 
irregular mixture of red and brown. Following the common 
evolution of tuberculous tissue, there may be a conservative or 
destructive termination to the process. In the one case a gradual 
fibrosis begins which eventually covers the affected tissue with a 
depressed, shining scar. In the other the surface breaks down, 
leaving a superficial ulcer whose edges are rough, elevated, and 
infiltrated, and covered in parts by crusts which extend from the 
centre. Variations in form have been given appropriate names, so 
that if the affected area has a number of warts on it one calls the 
variety lupus verrucosus ; if the outlines of the ulcer are wavy, 
lupus serpiginosus ; if there is a rich and luxuriant growth of 
granulations, lupus hypertrophicus. The course of the disease is 
irregular, and on the whole chronic. 

Treatment. — There is no doubt that many cases of tubercu- 
losis are curable, and the clearly defined evidence which we pos- 
sess of the healing of tuberculous process before a lesion has been 
known to exist, as demonstrated by the finding of scars after 
death, is enough in itself to encourage the physician never to 
cease in his efforts in any degree until the patient is dead. The 
dogged and steady persistence in carrying out every detail, no 



510 THE MEDICAL DISEASES OF CHILDHOOD 

matter how small, of a wise method of care will unquestionably 
tend to produce ease and prolong life. In many respects the suc- 
cessful care of a tuberculous patient is a matter of minutiae, of 
constant watchfulness, of unremitting activity. And the physi- 
cian must try with all his power to prevent a spirit of pessimism 
from dominating himself or his patient. Psychological treatment 
has its place as well as physical. 

Our first care, of course, must be in the way of prevention. 
Affected persons, those of a bad heredity who are in poor health, 
and those who have recently recovered from the disease, must not 
be allowed to marry until they are clearly beyond present danger. 
As a general rule, marriage should be forbidden until not only 
their general health but also their domestic, industrial, and climatic 
environment has been arranged with a view toward adequately 
protecting them from the probable likelihood of another attack. 
Following the same idea, such persons as are threatened should be 
placed in the most favorable circumstances to prevent the develop- 
ment of the disease, and best of all they should be removed from 
the family until a normal degree of health returns. This is espe- 
cially true of young children who are naturally in a condition of 
unstable equilibrium, and for whom every circumstance of ordi- 
nary life may go far to produce health or sickness. Their food 
should be as untainted as possible, of the best quality, wisely 
selected, and properly administered. They should be made to 
live as much as possible on a nitrogenous diet, with sufficient 
admixture of fats, sugars, and starches to give variety. These 
children should be encouraged to eat much, to eat often, and to 
allow sufficient time after any violent exercise to permit undisturbed 
digestion. The ventilation of their sleeping rooms must be excel- 
lent, and whenever possible they should sleep in the open air. 
Their clothing should be warm and not too heavy ; it should be 
sufficiently absorbent, and must be frequently changed. They 
should bathe often, and should always have the benefit of cool or 
cold morning douches. Exercise must be carefully regulated, 
must not be omitted for a single day, unless they are confined to 
bed, and should be taken in the open air. 

An infected child should be rigidly isolated, he should be 
removed to the country, and should live in the open air as much 
as possible. The climate should be moderate, dry, and not often 
subject to extreme changes. It should be such that the child may 



THE SPECIFIC INFECTIOUS DISEASES 511 

spend the greatest part of the day out of doors, eating there, and 
frequently sleeping there. No bed is quite as good as a hammock 
for such a patient ; for it is most easily aired and transported from 
one place to another on the grounds as occasion demands. All 
discharges — pus, sputum, fceces, urine, nasal mucus — must be 
burned or disinfected before being thrown in the common recepta- 
cles, and all clothing and household utensils should be boiled and 
cleansed by themselves, and kept from contact with those used by 
the rest of the family. Books and toys should be kept apart from 
other children, and so disposed as to be free from the responsibil- 
ity of carrying infection. 

With these patients the recommendations concerning food, 
clothing, exercise, bathing, and ventilation must be carried out in 
the most consistent manner possible ; one must keep in mind that 
drugs, while valuable enough, have no specific action, that the 
surest method of help is to develop every possibility of vital resist- 
ance and recuperation. A corollary to this proposition is to 
remove every possible weakness or obstruction to perfect function. 
For example, hypertrophy of the pharyngeal tonsil, chronic intes- 
tinal derangement, or any other obstruction to normal plrysiological 
activity, calls more urgently than in ordinary cases for correction. 
Above all, one must regard the localization of the disease not merely 
as disability of the part involved, but rather as a partial manifesta- 
tion of an infection that is doubtless wider than the objective symp- 
toms denote, and in addition may be, or may shortly become, general. 
Potentially tuberculosis of any part means tuberculosis of every 
part, for the whole includes every element into which it may be 
divided. 

The special methods of treatment are few : pulmonary tuber- 
culosis calls for the same treatment that similar non-tubercular 
inflammations of the lung necessitate. In addition to the care of 
the symptoms, stimulants and tonics must be liberally and wisely 
used. Among these, alcohol holds an important place, and strych- 
nine or mix vomica must be often and liberally employed. The 
organic preparations of iron may be needed to combat the anaemia 
that so often appears. Beechwood creosote is of value when it can 
be tolerated ; it may be administered with three times the quantity 
of tincture of gentian, the mixture then being added to a small cup 
of milk. Another unobjectionable method is to suspend it in a 
good malt preparation ; no matter how given, the doses may range 



«HH 



512 THE MEDICAL DISEASES OF CHILDHOOD 

from 0.03 to 0.3 gramme (J to 5 drops) three to four times a day 
according to the child's age. Cod liver oil may be used, but only 
where the child's power of digestion and assimilation are good 
enough to change and absorb it. In these pulmonary cases the 
factor of climatic treatment is of radical importance. The child 
should, with the least possible delay, be removed to a locality 
where the air is clear, dry, and sufficiently rarefied. The place 
should be so chosen that extremes of temperature are not common, 
nor should there be many obstacles in the way of living in the open. 

The treatment of tuberculous glands is one of tonics and stimu- 
lants, of exercise, and regulation of the general mode of life. Thus 
iron, strychnine, arsenic, the compound syrup of hypophosphites, 
and alcohol are of considerable use. Where the glands are within 
easy reach, especially if marked improvement does not follow the 
use of the designated remedies, the ordinary surgical procedures 
are in place. Disease of the bones calls for similar care — rest, 
nourishment, stimulation, and finally operation. A tuberculous 
kidney, when its fellow is not involved, may require removal ; 
and tubercular peritonitis, which is characterized by the presence 
of fluid, calls for laparotomy. When the testis, ovaries, tubes, or 
uterus are involved, operation may be useless because the rest of 
the body is doubtless also infected ; but if these organs constitute 
the main seat of the disease, they likewise should receive radical 
treatment. Disease of the brain and meninges can receive no 
more than symptomatic care, and in this way resemble most cases 
of tubercular livers, spleens, intestines, and other viscera. Tuber- 
culosis of the skin, lupus, calls for destruction of the pathologi- 
cal tissue by excision or caustics, and the covering of the freshly 
granulating surface by skin grafting. 

Prognosis. — The outlook varies with the age of the patient, the 
location of the disease, and the possibility of commanding all the vari- 
ous means of treatment. An infant with general miliary tuberculosis 
has very little chance of life ; if the disease takes the form of acute 
involvement of the lungs, most of all when there are characteristics 
of a rapid course, the termination is usually fatal. The chronic 
processes have a much better chance of life, or a fair measure of 
recovery. When the glands alone are involved, whether in the neck, 
chest, axilla, or elsewhere, with proper care the child ought in most 
cases to have a good chance to live and be comfortably healthy. 
The same remark is true of other parts where the diseased tissue 



THE SPECIFIC INFECTIOUS DISEASES 513 

may be reached by operation. Thus, the patient who suffers from 
the non-ulcerative form of tubercular peritonitis is generally restored 
to health, and almost regularly we expect a tuberculous bone to 
improve or heal after a well-timed and well-conducted operation. 
On the other hand, one cannot be so sanguine in speaking of the 
abdominal and thoracic viscera ; for the disease generally spreads 
so rapidly that tuberculosis of one means tuberculosis of many 
organs, and the penalty of a resulting general infection is death. 
Even in tuberculosis of the kidney, although the organ may be 
removed, the doubt of uncertainty, of the possibility of hidden 
infection in the fellow-viscus or some other structure, must remain 
for years in the mind. There is always the fact to terrify us that 
in most cases the bacilli are not entirely eliminated. The outlook 
in all such cases is uncertain ; one child may live, the next may 
die. In cerebral and meningeal infection the result is practically 
always death. In lupus the treatment may be long continued, 
but in most cases recovery results. 

Differential Diagnosis. — The main guide in any local or gen- 
eral manifestation of tuberculosis is the characteristic sympto- 
matology, and if one keeps this distinctly in mind most of the 
so-called doubtful cases after a compartively short period of 
observation become clear. A careful examination of the patient's 
previous history, of his heredity and environments, and whether 
he has recently had those exhausting diseases which predispose a 
child to tubercular infection, are important items in distinguishing 
this disorder. In the typhoidal type of the infection in infants, 
the absence of Widal's reaction, of characteristic temperature and 
eruption, and the long course of the symptoms are enough to 
clear any doubt. In pulmonary disease, confusion will occur 
only in the first stages, and then the doubt rests between a tuber- 
cular process and non-tubercular broncho-pneumonia. Here we 
need to keep in mind that the latter has an acute onset and usually 
a limited course, that resolution takes place more or less promptly, 
and usually leaves the lung clear. In tuberculosis there are 
generally prodromal symptoms, S} r stemic signs, a long course, in- 
volvement of other parts, and a delayed and imperfect recovery. 
In addition we may often be able to find in the vomitus sufficient 
mucus from the throat and bronchi to allow a microscopical exam- 
ination for the bacilli. The location may give a hint — not always 
trustworthy, however. Speaking in general terms one may say 
2l 



514 THE MEDICAL DISEASES OF CHILDHOOD 

that the non-tubercular broncho-pneumonia more generally attacks 
the lower than the upper half of the lungs ; the tubercular inflam- 
mation, on the other hand, more frequently attacks the upper than 
the lower half. The physical signs in both are too much alike to 
be distinguished. 

Diagnosis of disease of the urinary track may be rendered more 
certain by microscopical and bacteriological examination of the 
urine. In the glands we have to distinguish tuberculosis from 
the enlargements caused by ordinary, pulmonary, and gastroin- 
testinal disease, by syphilis, malignant disease of the chest, and 
Hodgkin's disease. The mere statement of the case is almost 
sufficient to clear up the difficulty, especially when one remembers 
that the general picture of tuberculosis is different from that of 
the other complaints, and that they in turn have their own peculiar 
characteristics. It is only in the beginning stages that doubt 
should exist, and here a short period of observation should effectu- 
ally clear up the difficulty. In tuberculosis of the intestinal and 
mesenteric glands, one may occasionally have much difficulty in 
distinguishing the disease from lympho-sarcoma. The main points 
of differentiation are the rarity of the latter disease, the absence 
of tubercular involvement of other parts, lack of tubercular his- 
tory and general tubercular symptoms, and the very gradual 
growth of tubercular deposits. Sometimes the diagnosis can be 
made only after extended observation. 

Tubercular peritonitis is to be distinguished from the non- 
tubercular variety and cirrhosis of the liver. The last-named 
disease is very rare in children, and when it does occur it presents 
a hard, small liver, more or less jaundice, and less temperature and 
gastro-intestinal symptoms than in tubercular peritonitis. In non- 
tubercular peritonitis there would not be the history of tuber- 
culosis ; moreover, it is a rarer affection except in cases of wounds 
or similar means of pyogenic infection. Finally, the ascitic fluid 
will supply material for microscopical and bacterial decision. 

Diagnosis in meningitis is not always possible in the early 
stages. Usually the confusing and doubtful diseases are gastric 
and intestinal disorders, and as these are much more frequent than 
tubercular meningitis, cases which involve rational doubt should 
not be decided upon until definite grounds for final judgment 
have been obtained. These grounds are discovery of past or 
present tuberculosis in any part of the body, continued disturb- 



THE SPECIFIC INFECTIOUS DISEASES 515 

ances of the gastro-intestinal track, increasing stupor, irregular 
pulse and respiration, convulsions, and in some cases opisthotonos. 
A further means of certainty is sometimes furnished by finding 
bacilli in the cerebro-spinal fluid obtained by tapping the lumbar 
portion of the spinal canal. One of the main objections is the 
difficulty of finding the micro-organisms in every case. 

Inherited Syphilis 

Syphilis is an infectious disease that is peculiar in the widely 
spread range of its lesions, their durability, and the great length of 
time over which it may extend. It may be communicated to the 
ovum in the act of fertilization, it may appear in children, and 
may infect old age. But with the characteristics of the ordinary 
acquired disease we have very little to do, since they are about the 
same at all periods of life. On the other hand, inherited syphilis 
is a thing apart whose features and results are important enough 
to call for careful consideration. 

Causes. — The disease is probably caused by a micro-organism ; 
in default of positive information writers have commonly referred 
to Lastgar ten's bacillus as the likely cause. The lack of a suitable 
medium in which this bacillus may be cultivated has hitherto been 
a bar to the acquirement of certain knowledge. But recently the 
consensus of opinion has decided that this bacillus in all likelihood 
is identical with the smegma bacillus. That the nature of the 
disease is microbic is testified to by our appreciation, in the light of 
our experience with antitoxines, of the law enunciated by Colles 
in 1837, that a new-born syphilitic child does not produce on the 
breast of his mother, who may seemingly be free from specific 
taint, any ulcerations as the direct result of contagion from suck- 
ling. We naturally put this phenomenon in the same class with 
those of immunity against diphtheria or smallpox. Moreover, we 
may add to it the complementary law of Profeta which enunciates 
the immunity of children, one or both of whose parents are syphi- 
litic. Some of these children continue immune against the disease. 

It is always necessary to distinguish sharply between hereditary 
syphilis and those cases of acquired disease which occur early in 
life. Thus it is possible, although the occurrence is rare, for a 
child to be infected during parturition. Also, he may contract the 
disease from being suckled by a syphilitic nurse, by being handled 



516 THE MEDICAL DISEASES OF CHILDHOOD 

and kissed by syphilitic persons, through the agency of infected 
foods, domestic utensils, toilet articles, linen and clothes, by sleep- 
ing with contaminated persons, through exposure in the rite of 
circumcision, and by sexual contact. These various means are to 
a certain extent accidental, and their likelihood changes according 
to the circumstances of the child. 

The exact share of responsibility that should be attributed to 
the father or the mother in hereditary syphilis is rather an aca- 
demic than a practical question. We know quite conclusively 
that an infected woman almost always passes on the disease to her 
child; that an infected father commonly, although not quite so 
regularly, brings about the same result ; that the certainty of in- 
fection varies with the shortness of time between the contracting 
of the disease by the parent or parents and the date of conception. 
The question of infection of the foetus is quite a different one. The 
view held in past times that there might be a direct transmission 
to the child is untenable ; it is true that the ovule may be infected 
at the time of conception by a diseased spermatozoon, but after- 
ward infection must occur through the indirect means of the 
mother who acts as a primary agent. Much discussion has centred 
about the length of time during which the possibility of intra-uter- 
ine infection existed ; in answer to the implied question one may 
state that reliable observers have considered a mother capable of 
infecting her foetus even when she has become contaminated as late 
as the seventh month. On the other hand, Diday believes that a 
woman who becomes infected during the first four weeks of gesta- 
tion may by promptly obtaining vigorous treatment ward off the 
danger from the infant. 

Lesions. — ■ The pathology of hereditary syphilis may properly 
be preceded by a glance at the changes which occur in the syphilitic 
placenta, on account of which abortion so frequently occurs. The 
villi, which at no time are lavishly supplied with blood, become 
vitiated by cell proliferation until their vitality is materially re- 
duced; this change continues until the epithelium and connective 
tissue stroma are likewise affected to such a degree that the circu- 
lation is more or less shut off. A like process goes on in the 
pouches into which the villi project, so that finally the placental 
nutrition is cut off either throughout its whole extent or in scat- 
tered areas. Accordingly abortion occurs, or the nourishment of 
the foetus is abridged. 



THE SPECIFIC INFECTIOUS DISEASES 517 

While it is true that some syphilitic children present no char- 
acteristic lesions after death, nevertheless they are more liable than 
others to inflammations of many parts of the body. Indeed, there 
is no portion that is necessarily exempt; but, on the other hand, 
some are especially liable to attack, notably the osseous, visceral, and 
serous structures. The long bones of syphilitic children are espe- 
cially liable to be involved, and mostly at the junction of the diaph- 
ysis and epiphysis. The temporary formation which constitutes 
the line of junction is broader and more irregular than normal, and 
consists in fairly large part of cartilage cells. This zone, instead 
of decreasing, may increase, and is bordered by a soft, rather 
vascular cartilage that is irregular in its composition. Finally 
the growth is so poorly controlled that as the areas of calcification 
and ossification increase, and the intermediary spots of soft tissue 
enlarge, the stability of the whole structure becomes seriously 
impaired. The perichondrium and periosteum become loose, thick, 
and irregular in contour, and the shape as well as the stability 
of the bone becomes altered. Thus the results may show them- 
selves in the form of an acute epiphysitis with a possible cleavage 
at the line of junction, or of the more chronic osteochondritis. In 
the latter the cartilage is first affected, its cells proliferate, and 
become soft and loose. Simultaneously there is a wasting of the 
intercellular substance. In extreme cases the inflammation may 
extend through the muscular tissue and result in an abscess, or 
it may involve a near-by joint. These changes are apt to occur 
very early in life, and should regularly be looked for, even if the 
parents of the child do not include the symptoms of swelling and 
tenderness in their history of the case. In older children there 
may be a periostitis of the long bones of the arms and legs 
which has nothing peculiar in its pathology. In other children 
the changes may be located in the fingers and toes, the proximate 
phalanges being attacked in preference to the distal. Although 
abscess formation is here likewise liable to result, nevertheless the 
ultimate integrity of the part is apt to be restored as soon as 
proper treatment is vigorously instituted. Such involvement is 
characteristic of very young rather than older children. Another 
favorite seat for bone deterioration is in the skull, where the 
softened tissue may by pressure exerted from both sides be thinned 
to a marked extent. The form of the skull makes craniotabes of 
the occipital bone the most common variety. 



518 



THE MEDICAL DISEASES OF CHILDHOOD 



In the lungs of still-born and young children the condition, 
known on account of its color as white pneumonia, is commonly 
seen. The process involves a part or the whole of a lobe, and 
consists of a diffuse fibroid infiltration. The epithelium is in a 
condition of fatty degeneration, the septa are thickened, and the 
alveoli are compressed by fibroid tissue. The process is plainly 
marked in the peribronchial areas, and the pleura is often involved. 
The formation of gummata in young children is at times apt to be 
replaced in older patients by areas of pus production. As the 




Fig. 109. — Infantile Hereditary Syphilis of Lung. X 30. 



result of these sclerotic changes, one rationally expects to find 
regions of emphysema, bronchiectasis, and atelectasis. In addition 
one occasionally sees a case of stenosis or ulceration of the bron- 
chioles, trachea, or larynx. 

The spleen is almost always enlarged, and the severer the 
grade of inflammation the more extensive are the changes in this 
organ. In infants there is a simple enlargement and hyperplasia 
of the tissue, and the capsule likewise may be thickened. In older 
children there may be a deposition of connective tissue that pre- 
serves the increase in size even after other pathological conditions 
may have become resolved. In the liver somewhat similar changes 



THE SPECIFIC INFECTIOUS DISEASES 519 

may be seen, with the exception that the interstitial inflammation 
occurs in the youngest children. The size of the organ is very 
much increased; the liver cells as well as the arterioles are squeezed 
and encroached upon by the new tissue, which gives a much lighter 
hue to the organ than it naturally possesses. The connective tissue 
may extend through a large part or the whole of the organ, or in 
other cases may be disposed in separated areas which at times may 
coalesce. In older children gummata of small size may be scat- 
tered here and there. In the pancreas a sclerotic involvement 




Fig. 110. — Gumma of Spleen, x 50. 

may occasionally be found ; a similar course regularly affects the 
kidneys, where the inflammation assumes the form of a chronic 
interstitial nephritis, complicated in some cases by the presence of 
gummata. The suprarenal capsules go through a like develop- 
ment, as may any part of the genitourinary s} T stem. Thus the 
urethra, or, more commonly, the body of the testicle, may be 
affected; and some years ago I saw a similar condition in the 
rudimentary prostate of a boy only two and a half years of age. 
There is no viscus, in fact, which is free from the danger. 

Among the parts most frequently attacked are the mucous 
membranes of the nose and throat. The inflammation is catarrhal, 



520 



THE MEDICAL DISEASES OF CHILDHOOD 



with the addition at times of the so-called mucous patches. In 
the nose especially there is a likelihood of this tissue's breaking 
down, and of the ulceration's being followed by slight or severe 
degrees of necrosis. A specific otitis with consequent deafness is 
sometimes seen, but not quite so often as an interstitial keratitis 
which is seen in infants of the youngest age, or even before birth. 
The associated lymph-nodes are regularly involved, but do not 
present any noteworthy features that are distinct from those seen 
in adults, with the possible exception of a greater readiness to 




Fig. 111. — Gumma of Liver. X 30. 



break down in suppuration. In the brain and spinal cord syphilitic 
disease is rare. Hydrocephalus from this cause is sometimes seen ; 
outside of this, the process may attack any part of the cerebro- 
spinal system, but so infrequently that the cases are to a certain 
extent regarded as curiosities. 

Symptoms. — In true hereditary syphilis there are no primary 
symptoms ; the secondary signs may appear a short or a considera- 
ble time after birth, and only rarely are they present when the 
child is born. The various compilations of Diday, of Roger, of 
Miller, agree in placing the ordinary period when the symptoms 



THE SPECIFIC INFECTIOUS DISEASES 



521 






appear as in the second half of the first month, although varia- 
tions in both directions may naturally occur. These children may 
be born in good or poor condition, the decision resting upon the 
virulence of their infection and the mother's nutrition ; the younger 
the child, the severer is the disease apt to be. Those who have 
symptoms at birth rarely live more than a few days or weeks. 
These characteristics are emaciation, prostration, asthenia; the 
skin is wrinkled, the face looks old, the temperature may be 
subnormal, the spleen and liver may be enlarged. Sometimes 




Fig. 112. — Syphilitic Cirrhosis of the Liver. X 30. 

there is an eruption of macules, papules, pustules, or blebs on the 
hands and feet. The cry is hoarse, and the nose is partly occluded 
by swelling of its mucous membrane and the resulting discharge. 
The children die because they have not the strength to live. 

Those children who are born in better condition retain their 
health for a month or less, in rare cases for a possible period of 
three and a half months. Then their strength begins to fail, they 
become fretful and assume a weazened expression. They regularly 
become troubled with a persistent coryza, and the voice may be 
muffled and hoarse. There may be mucous patches on the throat 
and anus, the lips may be fissured, and condylomata may appear. 






522 



THE MEDICAL DISEASES OF CHILDHOOD 



Bone symptoms may break forth, and visceral diseases of various 
locations are to be expected. 

The eruption appears in various forms ; its first location is gen- 
erally on the abdomen, face, and nates, from which it spreads to the 
rest of the body. Its mildest form is the macular variety; its color 
is a dull red, which disappears on pressure. Later on, the hue is 
coppery and permanent. Papules are more serious in their import 
than macules ; they are somewhat small in size and irregular in 
contour. The pustular syphilide may be seen in all stages from 



/• 





Fig. 113. — Induration of Kidney: Hereditary Syphilis. X 30. 



a changing vesicle to a completed pus formation. The worst of 
all is that made up of blebs or bullae, filled with serum or pus, that 
has for its favorite location the plantar surfaces of the hands and 
feet, and sometimes the legs and arms. At the same time, when 
the eruption is developing, one's attention is commonly attracted 
to the mucous membranes. All over the body these may according 
to their conformation be attacked by fissures and patches. In the 
angles of the mouth such thin clefts, which are tender and easily 
made to bleed, leave scars that always point to syphilitic disease ; 
they may also appear on the margin of the nose, and even more 



THE SPECIFIC INFECTIOUS DISEASES 



523 



commonly about the anus. The patches are oftenest found on 
mucous membranes or their margins ; but where the skin is thin 
and tender, or is irritated by friction, injuries, or any acrid discharge, 
they may likewise appear. At times they are hard to distinguish, 
but in general may be recognized as dull white in color, thin, 
slightly raised, and having a reddish border. 

One of the characteristic facts about these children is their 
liability to succumb to inroads upon their vitality. A faulty milk 
supply, which may mean no more than a temporary indisposition 



w^g 




Fig. 114. — Syphilitic Lymphadenitis. X 25. 

in a healthy child, may in a congenitally syphilitic baby threaten 
life itself. For this reason the ones that are artificially fed, espe- 
cially if their circumstances are not good, are poorly nourished, 
are commonly ailing, and are often unable to withstand the shock 
of ordinary physical disability. In some cases disorders of the 
gastro-intestinal track begin a series of sicknesses which succes- 
sively attack one portion of the body after another. In this con- 
nection I am reminded of a syphilitic child who began to suffer 
with laryngitis and rhinitis, followed at varying intervals by peri- 
tonitis, gastro-enteritis, iritis, otitis with consequent deafness, peri- 






524 THE MEDICAL DISEASES OF CHILDHOOD 

ostitis of the left femur, and then a similar process on the right 
side. Finally she died during an attack of broncho-pneumonia. 
These sicknesses extended over months, and during all this time 
the child was laboring under the pitiable disadvantage of inability 
to recuperate in sufficient degree from any one of the specific 
attacks, very much as a spendthrift continually takes more from 
his resources than he can add thereto. As a result of the steady 
physical deterioration an intense anaemia frequently ensues, char- 
acterized by a diminution of the number of red blood-cells, alter- 
ations in their form, decrease of haemoglobin, and a noticeable 
leucocytosis. This condition of the blood, if it is not very marked, 
may be overcome ; but severe cases are very dangerous. Especially 
so are the rare instances of haemorrhagic syphilis in babies in which 
the bleeding may occur from the mucous membranes or under the 
skin, either from no known cause or slight injuries. Under this 
heading various writers have put haemorrhage from the umbilicus 
which occurs within a few days after birth. 

The symptoms of disease of the bones may easily be deduced 
from the pathological changes plus the ordinary course due to 
swelling, pain, and loss of function. It is sufficient to emphasize 
the necessity of carefully examining the long bones of every sus- 
pected or known case of inherited syphilis, and of regarding the 
first sign of tenderness or deformity as the probable precursor of 
serious changes. One should likewise watch for disease of the 
nails, and phalanges of the fingers and toes. There may be sup- 
puration of the matrix around the upper margin of the nail, or 
the nails themselves may crack, break, chip off, or become wholly 
exfoliated. In either case the nails are apt to be furrowed, creased, 
irregularly thickened and discolored ; at times they may be so 
much distorted as to suggest the picture of a claw. With or with- 
out these changes there may be disease of the phalanges, which 
more commonly occurs in the proximal than the distal segments. 
The inflammation is primarily one of the bone and periosteum ; 
the swelling is hard and fusiform, and only rarely involves suppu- 
ration of the muscles and skin. 

The false paralyses of early hereditary syphilis are not matters 
of serious moment, nor are they permanent. Very commonly the 
loss of function is not due to organic lesions of the nerve tissue, 
but rather to pathogenic conditions of the bones and muscles, 
which render action, movement, and even handling extremely 



THE SPECIFIC INFECTIOUS DISEASES 525 

painful. The existence of such disabilities, if no other sign is 
present, should always suggest the possibility, and often the prob- 
ability, of inherited syphilis. 

An exceedingly interesting class of cases is what is called late 
hereditary syphilis. Whether one will regard these cases as the 
delayed expression of inherited disease or the tertiary symptoms 
of acquired syphilis whose earlier stages have not been noticed, 
depends upon one's mental equation, training, and experience. 
Their characteristics closely resemble those of tertiary syphilis, and 
there are good reasons for believing them to be nothing more than 
tertiary symptoms. Nevertheless, as both views have able sup- 
porters, the matter cannot and should not be here treated as other 
than an open question. The principal instances of these cases are 
seen in the bones ; there may be disease of the long bones and 
their periosteum, and also of the skull. The deformity may be 
considerable, but the pain and disability are often much less than 
in the early form of the disease. The skull is apt to have a heavy, 
square appearance, and the frontal prominence may be quite notice- 
able. The bones of the nose may be weakened, thickened, dis- 
torted, or necrosed. The hard palate is sometimes high and arched, 
and a necrotic process similar to that seen in the nasal structures 
may attack it in the median line. Many of these changes are not 
only due to the poison of the disease, but must also be in part 
attributed to a deficient and vicious nutrition. This is especially 
well seen in the second set of teeth. While all may be affected, 
the central upper incisors are the ones most plainly marked. They 
are so poorly developed that they lack their usual length and 
breadth, they are set irregularly in the gums, and according to 
their general deformities have been called screw-driver teeth, peg 
teeth, and the like. The classical form known as Hutchinson's 
teeth designates those upper incisors whose lower margin are 
grooved or notched in the centre. This is the result of softening 
and attrition of the enamel, and may occur in other diseases of 
malnutrition. Throughout the body there may be visceral changes 
which follow the general plan of tertiary disease in adults, the 
most frequently affected parts being the excretory and assimila- 
tive systems. The diseases of sense organs that are most often 
observed are interstitial keratitis with or without iritis, and a 
chronic otitis media whose ordinary end is loss of hearing. The 
skin is, in weak and poorly cared-for children, easily broken down, 



] 



526 THE MEDICAL DISEASES OF CHILDHOOD 

and a characteristic ulceration ensues that differs in no way from 
syphilitic ulcers in adults. 

Treatment. — Prophylaxis in syphilis is one, if not the most im- 
portant, part of treatment with which the physician must concern 
himself. The mother must be subjected to vigorous treatment, 
if she or her husband had the disease before conception, or if she 
or her husband acquired the disease after conception and before the 
birth of the child. A child born of such parents, so long as his 
heredity is known, and even if at • birth he presents no symptoms, 
should be put under treatment until his normal development is 
fairly well assured. If the disease is not known or suspected at 
first, the treatment must be instituted with thoroughness as soon 
as the first symptoms appear. If a wet-nurse is to be employed, 
every applicant for the position must be rigorously examined and 
proved to be free from the disease before she is allowed to touch 
the child. And on the other hand, a syphilitic infant should 
never be suckled by a healthy wet-nurse. The physician's respon- 
sibility is as great in one case as in the other. 

As in adults, our main reliance is placed upon the administra- 
tion of mercury. This may be given in inunctions, in fumiga- 
tion, or internally. The inunctions are deservedly the favorite 
mode of prescription, since we thereby avoid all injury to the 
sensitive gastro-intestinal track. The ointment of the oleate of 
mercury, either alone or mixed with lanolin or vaseline, or the 
officinal mercurial ointment mixed with an equal quantity of cold 
cream, may be rubbed into the inner surfaces of the arms and legs, 
one limb after the other being employed in regular rotation on 
successive days. Another way, and a very good one, is to spread 
about 0.75 to 1.0 gramme (gr. xij to xv) of the ointment on a piece 
of lint which is to be firmly held by a roller bandage to the part 
selected. The warmth and movement of the body cause absorp- 
tion, while the disadvantages of rubbing the ointment into the 
skin are done away with. If for any reason, such as erythema of 
the skin, it is necessary to discontinue this means, the internal 
administration of one of the soluble salts of mercury should be 
employed. The bichloride is commonly used in doses of 0.0003 
to 0.0006 gramme (gr. giro to Too)- The disadvantage in this 
is its disposition to irritate the gastro-intestinal track. In its 
place I have had satisfaction in using the protiodide in doses 
of 0.003 to 0.006 gramme (gr. ^ to -j 1 ^-) three times daily. In 



THE SPECIFIC INFECTIOUS DISEASES 527 

markedly severe cases where it is imperative to make an imme- 
diate impression on the disease, hypodermatic injections of the 
chloride in doses of 0.0003 gramme (gr. 2 o^o) f° r a ^ ew times only 
may be given. In the late attacks one may use the iodide of 
potassium or the ordinary mixed treatment for the same indica- 
tions as in the tertiary stage of adults, the quantity having been 
made suitable to the age and condition of the patient. 

The administration of mercury is not the only matter of im- 
portance; for the child's general condition is often so poor, and 
the degree of anaemia may be so severe, that much attention 
should rightly be given to them. The food, if artificial, should 
be most carefully regulated and modified, and such details as 
bathing, rest, clothing, and exercise should be scrupulously super- 
vised. In many instances it will be necessary to administer tonics 
early in the disease, and to continue their use until the patient is 
in good condition. As much judgment and resourcefulness may 
be shown in this direction as in the search for the most favorable 
method of exhibiting mercury. 

Prognosis. — The outlook is not very encouraging ; even if 
children do not die, they nevertheless may have such poorly nour- 
ished bodies that some form of disease is constantly threatening ; 
and in such cases intercurrent acute sicknesses are apt to take 
a severer course than in children of a better heredity. The pro- 
portion of deaths depends upon the youth of the patient, the 
malignancy of the disease, the promptness and thoroughness of 
treatment, and the circumstances of the patient's home. These 
factors are so variable that statistics are not of much use. If we find 
in a public hospital, whose patients come from the poorest, the 
most ignorant, the most unfavorable classes in the community, a 
mortality of from fifty per cent to sixty per cent, we may on the 
other hand learn in private practice that eighty-five per cent to 
ninety per cent of syphilitic children live. Under the most favor- 
able conditions the mortality may be even further reduced. 

Differential Diagnosis. — The picture of hereditaiy syphilis is 
usually so clear, and the confusing elements are generally so easily 
eliminated, that a mistake in diagnosis should not often be made. 
The history of this specific disease in the parents, and the acute 
symptoms in the young child,.such as snuffles, hoarseness, the skin 
eruption, the mucous patches, and anal condylomata, the tenderness 
in the bones, and the general malnutrition, all go to make con vie- 



528 THE MEDICAL DISEASES OF CHILDHOOD 

tion in one's mind. In the late form, the advanced bone disease, 
the small, poorly nourished, and irregularly developed teeth, the 
flat head and sunken nose, the rhagades, the marks and ulcers on 
the skin surface — these are sufficient to lead one to the truth of 
the matter. In case one finds symptoms of visceral involvement 
or the presence of gummata, the characteristic treatment will 
almost always relieve the patient without delay, and confirm the 
diagnosis. 

Malaria 

Malaria is an acute infectious disease caused by the hsematozoon 
described by Lave ran in 1880, and later named Plasmodium mala- 
rias by Marchiafava and Celli. It flourishes in greatest activity 
and luxuriance in hot climates, especially in the basins of the 
large rivers, and in swampy ground. In temperate zones it is not 
nearly so frequent, nor is its virulence nearly so great. In these 
climates, low, undrained ground, most of all where an impervious 
layer of clay is near the surface, and holds stagnating water within 
reach of the air, is the usual malarial locality. In cities large and 
deep excavations, tearing up of streets, residence near undrained 
parts, river fronts, and dumping grounds, are the usual means of 
infection. The plasmodium finds its way into the body through 
the inspired air, and Ross claims to have produced the disease in 
persons who drank water in which the bodies of mosquitoes that 
carried the hsematozoon in their bodies had died. The disease is 
most common in the spring and early summer, somewhat less so in 
the autumn, and least abundant in the winter. Children are fre- 
quently attacked, more often than adults ; moreover, they are 
liable to show irregular forms, even more so than mature patients. 

Lesions. — Most of the changes which occur in malaria are 
confined to the blood, and to a smaller degree to the liver and 
spleen. The plasmodium enters the red corpuscles where it under- 
goes a series of changes in form ; it increases in size, becomes pig- 
mented, and then segments. Finally it presents the picture of a 
many-armed rosette about whose centre the pigment granules 
cluster. The process of division produces from twelve to twenty 
units, which finally become free by the rupture of the enclosing 
capsule, and prepare to enter other corpuscles. The evolution 
takes forty-eight hours, and constitutes the so-called tertian form 
of the disease. It is possible that there may be two sets of plas- 



THE SPECIFIC INFECTIOUS DISEASES 



529 



modia which mature on successive days, thus producing the double 
tertian or quotidian form. 

It is probable that there is more than one form of plasmodium ; 
at any rate in the so-called quartan fever the appearance and evo- 
lution of the hsematozoon are somewhat different. In the simple 
form it matures at the expiration of seventy-two hours. Likewise 
there may be a double quartan fever with two groups which may 
mature on successive days with an interval of one free day, or a 
still more complex combination of three groups, the triple quartan, 




K 



\f 




Fig. 115. — Spleen in Acute Malaria, x 220. 



one of which matures on each successive day. When the matur- 
ing organism segments the process is marked by the characteristic 
phenomena of chill and fever in the patient. 

Still other forms of plasmodium have been noted whose seg- 
mentation takes place in the bone marrow, the liver, spleen, and 
other viscera. Not enough is at present known about them to 
classify them properly as far as concerns their evolutionary 
changes and the symptoms which they produce. All that one 
may say is that they are irregular, and the symptoms are likewise 
different from the ordinary type in irregularity of seizures and 
2m 



530 



THE MEDICAL DISEASES OF CHILDHOOD 



continuance of fever. Among these we may recognize a ring- 
like, highly refractile, and imperfectly pigmented form, a flagel- 
late form, and the crescent form of Laveran. This last-named 
variety is especially connected with the sestivo-autumnal fever, 
and produces a very troublesome attack. But no matter what 
the form may be, all are attacked by leucocytes which keep up a 
militant phagocytosis. As a result of pigment production, of 




PULSE, RESPIRATION AND TEMPERATURE CHART OF INTERMITTENT FEVER. 
AGE, 6 YEARS. 

pmftK, , PCeplPATinM TFMPFRATIIRP 

Fig. 116. 



breaking up of red corpuscles, and the formation of free melanin,. 
a more or less active melaneemia may exist ; and in severe cases 
marked by a large mortality of red corpuscles there will be a corre- 
sponding anaemia and heemoglobinsemia. The spleen and liver 
undergo interstitial changes, the mucous membrane of the gastro- 
intestinal track and the kidneys show evidences of acute degener- 



THE SPECIFIC INFECTIOUS DISEASES 



531 



ation, and a possible thrombosis of the cerebral capillaries may 
occur. 

Symptoms. — Inoculation experiments show an incubation 
period of ten, eleven, or twelve days ; in the unclassified irregular 
forms the period ranges from three to five days. The double- 
tertian and tertian types are often seen, but the quartan, the 
double- and triple-quartan are rare. The paroxysm is divided 



PULSE 


RESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


n 


12 


13 


14 


15 


170 


TO 


FAH. 
108 


CEN. 

42.2 
































160 


65 


107 


41.6 
































150 


60 


106 


41.1 
































HO 


55 


105 


40.5 






i 
I 








X 


X 


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X 


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130 


50 


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PULSE, RESPIRATION AND TEMPERATURE CHART OF TERTIAN INTERMITTENT FEVER. 

AGE, 9 YEARS. 

X= QUININE! PULSE _____«._ RESPIRATION _.__.__ tfmppratiirf' 



Fig. 117. 



into a cold and hot stage. The onset of the first is marked by 
weariness, lassitude, disturbances of the gastro-intestinal track, 
general pain, and finally a chill. The child feels cold and 
depressed; the surface feels cold, but the temperature of the 
rectum begins to rise. This stage lasts from a few minutes to 



532 THE MEDICAL DISEASES OF CHILDHOOD 

one and a half or two hours, and is followed by a fall of tempera- 
ture and a return of warmth which gradually changes to a striking 
heat. The skin is then hot and dry, the eyes are shining, the 
face seems congested, the heart action is hard, forcible, and rapid. 
After an interval of from one to three hours, the skin is bathed 
in sweat, the temperature falls to about the normal, and the child 
drops into a quiet sleep. 

There is usually an enlargement of the spleen and less often 
of the liver. There may be in addition disorders of the stomach 
and intestines, irritations of the skin, bronchial or pulmonary 
congestion. These symptoms are more apt to appear in chil- 
dren than in adults. They likewise are liable to severe nervous 
and circulatory depressions; the attack may be ushered in with 
convulsions, or by a chill followed by convulsions. In other 
cases there will be marked cyanosis and general prostration. In 
other cases periodic frontal headaches constitute one of the main 
features of the disease; occasionally the child complains mostly 
of indefinite depression, lack of energy, general massive pains. 
Occasionally one sees distinct nervous manifestations that stand 
out prominently in the mixture of indefinite symptoms : in one 
child there may be a localized neuralgia, oftenest in the face, 
arms, or chest; in another a multiple neuritis, in another a 
diarrhoea of a purely nervous type. The pernicious form is very 
rarely seen, and when it does occur it is usually in a child who has 
recently come from a warm or tropical climate. Some mention 
should be made of those very irregular cases, which generally occur 
in the autumn, characterized by continuous fever, or gastric disorders 
and general prostration which persist for several days at a time. 

Among the cases occurring in the autumn and the latter part 
of the summer — the gestivo-autumnal type — there is a notable 
percentage which run not only an irregular but also a severe 
course. The attacks may be long drawn out, so that they occa- 
sionally coalesce and give a continuous fever ; or they may be 
irregularly intermittent ; in other cases the paroxysms may at first 
be not distinctive, but may represent a combination of small chills, 
gastric disturbances, anaemia, and marked depression. Some of 
these irregular attacks may be acutely dangerous to life, and on 
account of their destructive course have been called pernicious 
malaria. This term includes the so-called algid, comatose, and 
hemorrhagic forms. 



THE SPECIFIC INFECTIOUS DISEASES 533 

In the large cities, where sanitation is steadily improving, the 
type of the disease seems to be milder and less characteristic than 
in former times. There is more and more variation from the 
classical, intermittent form, from the ordinary manner of onset. 
In place of the regular picture, one sees a periodic recurrence of 
signs that usually belong to some common visceral or functional 
disturbance. In such cases diagnosis is often very difficult until 
the blood has been examined and quinine prescribed. In these 
children, as well as those who have too soon abandoned treatment, 
the sub-acute and chronic forms of malaria occur and present the 
signs of marked anaemia, various and indefinite functional dis- 
orders, nervous symptoms, enlarged spleen and liver, and visceral 
disturbances. All the phases of pronounced secondary anaemia 
are present, including diminution of red and white blood-cells, 
dyspnoea, haemic murmur, and great general depression. The 
patient's resistance to disease is much reduced, so that he easily 
contracts intercurrent disorders. The picture of this malarial 
cachexia bears a notable resemblance to that of pernicious anaemia, 
although it more readily responds to appropriate treatment. 

Treatment. — The preventive care includes living in a well- 
drained locality and the drinking of pure water. If the ground is 
wet or marshy, it should be reclaimed ; but often the quickest and 
surest preventive is removal to a healthier place. When the dis- 
ease has found a lodgement, it must be combated with quinine. 
The least objectionable salts for internal administration are the 
bisulphate and hydrochlorate, dissolved in water, or, for older chil- 
dren, enclosed in capsules. The method which I have found most 
useful is to give three doses per day, the one before the paroxysm 
being twice as large as the others. Thus, for a child of five years 
whose paroxysm occurs at noon every day, the early morning dose 
would be 0.2 gramme (gr. iij ss), the dose before noon 0.4 gramme 
(gr. vij), and the evening quantity the same as the morning. The 
large dose will kill the newly formed spores produced by segmenta- 
tion, and the expected chill of forty-eight hours in advance will not 
occur. If the child is unable to take the drug by the mouth, it 
may be administered in double quantity by the rectum. In a few 
urgent cases where the depression and prostration are very urgent, 
the drug may be given hypodermatically ; for this purpose the 
bimuriate may be used in doses of 0.1 gm. (gr. ij). During the chill 
and the fever the care of the patient is purely symptomatic ; for 



534 THE MEDICAL DISEASES OF CHILDHOOD 

the first one may use heat in various forms — hot-water bags to the 
feet, sufficient blankets, hot drinks. Some children find relief from 
a very hot bath, followed immediately by being wrapped in warmed 
blankets. For the fever, one may use cool baths, sponging with 
alcohol and water, and the application of an ice bag to the head. 
The sub-acute and chronic cases improve best under the administra- 
tion of arsenic with small doses of quinine, or such a mixture as 
arsenic and strychnine. If the spleen and liver continue large 
in spite of these drugs, some improvement may be obtained by 
massage and systematic exercise. All cases, when convalescence 
sets in, require the use of iron, with which arsenic may often 
be advantageously combined, until the anaemia has passed away. 
Finally, obstinate cases and those that are left much weakened 
are benefited by removal to a healthy neighborhood where the 
conditions of soil, climate, and general mode of life are favorable. 

Prognosis. — The outlook is almost always good. In temper- 
ate climates the disease is very rarely fatal. The main question is 
one of diagnosis in irregular and doubtful cases, which an exami- 
nation of the blood will determine. Unless treatment is very 
thorough and long continued, the likelihood of recurrence is great, 
especially in the late spring. In some cases the disease, after the 
lapse of a variable time, is very apt to assume one of the nervous 
forms with a sub-acute or chronic course. These in turn demand 
patient treatment and untiring watchfulness for their successful 
handling. 

Differential Diagnosis. — The fact that malaria is so multiform 
in children permits of some confusion ; nevertheless, this disease is 
too often used as the most convenient term for a congeries of symp- 
toms that is not thoroughly understood. A malarial attack with 
cerebral symptoms has been mistaken for meningitis, or the stupor 
that one occasionally sees has been diagnosed as heat stroke. At- 
tacks accompanied by vomiting and diarrhoea have often been 
called gastro-enteritis or ileo-colitis. Malaria has been diagnosed 
as typhoid fever and vice versa, but the Widal reaction in the one 
and the presence of the plasmodium in the other are characteristic 
tests. The instances of confusing malaria with tuberculosis, 
broncho-pneumonia, septicaemia, pyaemia, endocarditis, and pyelitis 
are classical. The best way to guard against these errors is to 
keep as close as possible to the few tests of which we are certain. 
A thorough examination of the blood is the best of all ; in addition, 



THE SPECIFIC INFECTIOUS DISEASES 535 

one should try to obtain a history of residence in malarial locality, 
to distinguish the element of periodicity and an enlarged spleen. 
The diagnosis can be clinched by noting the effect of quinine. If 
there is any delay in effecting improvement, the case is either not 
malaria, or a complication with some other disease. In some 
irregular cases, which by the way are apt to occur in the autumn, 
the blood-examination may be doubtful ; it is then advisable to 
puncture the spleen with a fine needle to obtain a sample of blood 
that commonly gives a large amount of plasmodia. Before taking 
this step, one must assure oneself that the swelling of the spleen 
is not due to syphilis, to rachitis, anaemia, leucaemia, or Hodgkin's 
disease. 

Weil's Disease 

This disease was first described by Weil in 1886. It occurs 
as the result of infection by bacillus proteus fluorescens, which 
was isolated and named in 1891 by Jaeger. The patient becomes 
contaminated by eating decomposing meat and drinking infected 
water. The bacilli are found in the urine, the internal organs, 
and pus cavities. 

Lesions. — The lesions consist of a fatty degeneration of the 
kidneys and a cloudy swelling of the renal epithelium ; the liver 
shows a fatty degeneration, and a similar appearance may be seen 
in the spleen. In these and other viscera there is a variable 
degree of small-celled infiltration, and in one or more organs 
various amounts of haemorrhage may occur. In general terms, 
the changes may be said to represent an acute parenchymatous 
inflammation. 

Symptoms. — The symptoms cannnot be readily interpreted ; 
in their simplest form they consist of headache, moderate fever, 
prostration, and abdominal pain. The liver and spleen are slightly 
enlarged, and possibly tender ; there is almost always some degree 
of jaundice, and commonly the patient complains of articular pain. 
There may be nausea and vomiting, and possibly constipation. 
The stools on account of the obstructive hepatitis are dry and 
light colored. Albumin may commonly be found in the urine, at 
times accompanied by casts, and rarely by blood. The patient 
has a liability to pus-formations. 

Treatment. — The treatment is largely symptomatic. The 
patient should be confined to bed, and the bowels must be emptied 



536 THE MEDICAL DISEASES OF CHILDHOOD 

by small and repeated doses of calomel followed by a saline. The 
body should be sponged two, three, or more times a day, according 
to the range of fever. The food should be fluid and easily 
digested, and stimulants may be needed in liberal doses. The 
main drugs that are indicated are a few doses of bromide of soda 
to relieve pain and irritability, followed, when these symptoms 
have subsided, by strychnine or nux vomica, with or without the 
compound mixture of rhubarb and soda. The course of the dis- 
ease is rarely longer than a week or ten days, and in most cases 
the patients recover. 

Differential Diagnosis. — The disease may possibly be confused 
with acute hepatitis, typhoid fever, relapsing fever, and acute 
arthritis. The main diagnostic features are the enlargement of 
liver and spleen, jaundice, abdominal and articular pain, and the 
short course. If Jaeger's bacillus proteus fluorescens is found 
in the urine or a pus cavity, the diagnosis is at once confirmed. 



^^■■^^■^^Mi 



CHAPTER XXII 

NERVOUS DISEASES 

Acute Leptomeningitis 

This disease is known also as purulent meningitis, acute inter- 
nal meningitis, acute simple meningitis. It is an inflammation of 
the pia mater, which commonly involves the arachnoid and often 
the inner layer of the dura mater. . 

Causes. — The disorder is generally due to bacterial invasion. 
It most frequently follows the acute infectious diseases, such as 
acute lobar pneumonia, erysipelas, ulcerative endocarditis, septi- 
cemic processes. Or it may begin with an injury which is not 
great enough necessarily to produce fracture of the skull or spinal 
bones. In some cases it may not be possible to find any cause, 
and one may hear such cases referred to an indefinite over-exertion, 
heat stroke, exposure, possibly a fall. 

Lesions. — In addition to the congestion of the vessels, there is 
an exudation of serum, fibrin, and pus in varying quantities. The 
three factors may be evenly mixed, or any one may predominate 
over the others. The serum, pus, and fibrin are held in the meshes 
of the pia mater so that the membrane looks thick and oedematous. 
Fibrin and pus may be collected in thick, heavy lines along the 
blood-vessels, or several of these lines may coalesce and cover con- 
siderable areas. When the exudate is very plentiful it may fill up 
the spaces between the convolutions, and form a cast of the con- 
vexity. It may make its way from the pia mater along the vessels 
into the cortical substance of the brain, which thereupon becomes 
infiltrated, oedematous, and degenerated. There may be a large 
number of red and white blood-cells in the exudate which get 
there by haemorrhage, or diapedesis, and emigration. Cultures 
will show the presence of one or more varieties of bacteria accord- 
ing to sort of infection present. These, with the exudate, may 
extend to the ventricles and along the cord. The changes which 
are thus produced may persist for weeks after the acute inflamma- 

537 






538 THE MEDICAL DISEASES OF CHILDHOOD 

tion has subsided. There is a strong possibility of the sequence 
of chronic meningitis. 

Symptoms. — The disease usually begins in a quiet, gradual 
fashion. The child complains of weariness, dizziness, and nausea. 
He is stupid, cross, and complains of indefinite pains. These symp- 
toms may improve, remain stationary, or increase. Occasionally 
they may so far improve that they ultimately pass away. As a rule, 
they very soon become more serious ; the nausea may be followed 
by vomiting, or vomiting may come without warning, before or 
after meals. It is projectile, more or less violent, and often is not 
associated with any gastric disturbance. Weakness increases very 
rapidly, the temperature rises irregularly, often attains a height of 
40° or 40.5° C. (104° or 105° F.), and the pulse changes from quick 
to slow and irregular. There is much pain in the head which the 
child commonly refers to the forehead. Gradually the restless- 
ness gives way to apathy; photophobia becomes marked and con- 
vulsions may now appear. Constipation is marked, the abdomen 
is retracted, the pupils lose their contraction, and become dilated 
on one or both sides. Following the convulsions there may be a 
spastic rigidity of the neck or limbs, and in some cases opisthoto- 
nos sets in. This condition lasts only a short time ; without much 
delay the disease begins to resolve or hurries on to a fatal end. 
On the one hand, the symptoms may gradually become milder, in 
some instances falling into a sub-acute or chronic state. On the 
other, partial paralysis may set in, there is loss of sphincter control, 
and vaso-motor disturbances develop progressively. The respira- 
tion assumes the Cheyne-Stokes type, the child becomes blind from 
optic neuritis, falls into unconsciousness, and finally dies. 

Treatment. — The care of these cases is symptomatic. The 
sick-room is to be kept dark and quiet. The diet is to be fluid 
and easily digestible. The bowels are to be moved as often as 
necessary by means of calomel and a saline, or by enemata. An 
ice bag should be kept on the head, and the pain and restlessness 
may be overcome by antipyrin given in solution with a cardiac 
stimulant. If the stomach is unable to retain the food and medi- 
cine, they should be given by rectum. 

Prognosis. — Complete recovery is not common. Of course 
there are cases that seem to bear no traces of the past disease ; but, 
as a rule, those children who survive are left more or less incom- 
petent in mind or body, or both. The extent of the lesions and the 



NERVOUS DISEASES 539 

degree of severity have much to say in the probable outcome of 
the sickness. 

Differential Diagnosis. — There is much difficulty, in the gen- 
eral run of cases, in promptly arriving at a diagnosis. Usually 
the mistake of too rapid recognition is made, so that the cerebral 
symptoms which attend some attacks of the acute infectious fevers 
and otitis media are wrongfully interpreted as signs of leptomenin- 
gitis. One should keep in mind the main characteristics of the 
disease, — the gradual onset, pain in the head, projectile vomiting, 
unequal pupils, convulsions, and stupor. 

Chronic Leptomeningitis 

Chronic inflammation of the pia. mater usually has a history of 
a preceding acute attack. In some few cases its course from the 
outset may have a chronic character. In the latter case syphilis 
is the only known cause, although there are cases which arise 
from a different aetiology. Occasionally we see a case which has 
an apparent tubercular connection ; but as a rule we are not justi- 
fied in making a more definite assertion concerning this cause. 

The lesions are the natural outcome of the acute changes. 
The pia mater is thickened in areas of various size, it has deposits 
of connective tissue, and is bound down by adhesions to the brain 
or dura mater, or both. The fourth ventricle may be shut off, and 
some distension of the lateral ventricles usually results. In the 
exudate there may or may not be a small amount of pus. The 
Pachionian bodies may be increased in size. 

The symptoms are of the same nature as those of the acute 
form, but instead of running a steady course they come in remis- 
sions and exacerbations. There are periods of stupidity and pain 
in the head; there may be nervous disorders and irregularities of 
the pupils as well as of visual function. During the exacerbations 
there may be spastic rigidity, exaggerated reflexes, convulsions, 
vomiting of a projectile type, and even opisthotonos. If the 
amount of fluid in the closed ventricles is sufficiently large, the 
child will suffer from pressure effects, such as epileptic attacks 
and paralysis involving a large or small area. 

Treatment. — Since the only direct, known cause of this condi- 
tion is syphilis, iodide of potassium should be given whenever 
there is any reason to suspect the existence of this specific disease. 
Otherwise the treatment is general and symptomatic. Thus, in 






540 THE MEDICAL DISEASES OF CHILDHOOD 

those cases which give a tubercular history, one can prescribe no 
one drug which has an inevitable value for all. 

Prognosis. — The disease may continue for two, three, or even 
many more months. In all excepting the syphilitic cases the 
chances of recovery are very small. But even if, as a very 
unusual occurrence, recovery should take place, it will be under 
such conditions of mental and physical disability that little would 
thereby be gained. 

Differential Diagnosis. — The main diagnostic points are in- 
volved in the chronic course, apathy, vomiting, headache, convul- 
sions, and opisthotonos. It will not be difficult to distinguish it 
from tubercular meningitis, for the evidences of tubercular history 
and infection are wanting. Marasmus may infrequently give a 
certain amount of opisthotonos, but this one factor is not enough 
to confuse the two diseases. The chronic inflammations of the ear 
may in their acute exacerbations provoke some cerebral symptoms, 
but if from this cause a meningeal inflammation resulted, the 
course of the disease would not be very long. 

Pachymeningitis 

Inflammations of the dura mater may be confined to the exter- 
nal layer or the internal layer, and are accordingly named. Gen- 
erally, however, the inflammatory process is not so sharply marked, 
and may penetrate from one layer into the substance of the mem- 
brane, and even into the other layer. It may be acute or chronic. 

Acute external pachymeningitis generally follows injuries of 
the skull and disease of the mastoid cells, the inner and middle 
ear. The inflammation produces congestion, thickening, and soft- 
ening of the dura mater. The affected area is generally small; 
on it pus collects and thence may spread in all directions. In 
other cases the process may be confined to the original space, and 
finally be absorbed. 

Acute internal pachymeningitis may follow inflammation of 
the outer layer, the acute infectious diseases, pyaemia, syphilis, 
or syphilitic bone disease, or may occur without any known cause. 
The membrane is congested, thickened, and covered with pus. 

The symptoms of the external form are clearly distinguished 
only when the inflammation is so confined that local pressure 
effects are produced. In children the disease generally compli- 



NERVOUS DISEASES 541 

cates mastoid or middle-ear suppuration, and gives no especial 
signs. The internal form practically never gives separate symp- 
toms, for in its inflammation it involves the pia mater, whose 
symptoms are so impressive that they alone can be seen. 

Chronic pachymeningitis is almost always internal. There is 
a chronic thickening of the membrane, with the formation of con- 
nective tissue and adhesions. When the process involves the 
outer layer as well, the whole membrane may become bound 
down to the skull. In children the most important form of 
chronic pachymeningitis is the so-called hemorrhagic internal 
meningitis. Its causes are unknown, and in some cases it is not 
distinctly recognized until autopsy. Examination shows the pres- 
ence of fine connective tissue which supports in its meshes a 
large number of fine vessels, the outgrowth of the dural vessels. 
From these capillaries numerous extravasations of blood as well as 
hemorrhages may take place. The amount of blood varies from 
a minute to a fairly large amount. In the intervascular spaces 
are variously shaped cells and blood-cells, pigment, and chalky 
concretions. The new tissue becomes gradually thicker and 
denser, and finally its vessels are unable to withstand the increas- 
ing fibrosis. Under this fibrous covering large and small hemor- 
rhages occur through the delicate vessel walls, and with the newly 
formed tissue produce varying amounts of pressure upon the brain. 
These pressure effects may be thus created under any part of the 
dura mater, although their usual site is on the convexity. 

Symptoms. — The less severe forms of pachymeningitis may, 
and commonly do, give no symptoms during life. When, how- 
ever, a hemorrhage occurs, the effect is directly seen in nausea, 
vomiting, convulsions, unconsciousness, followed by paralysis in 
commensurate degree of the parts of the body which are controlled 
by the compressed brain. The respiration is slow, irregular, and 
sometimes of the Cheyne-Stokes variety. The pulse is likewise 
slow, irregular, and soft. There is little rise of temperature, and 
in mild cases there may be none. In such cases, after a period 
of active cortical irritation, the symptoms subside, and the child 
recovers, bearing usually some partial paralysis. Death may take 
place immediately, or after repetitions of the attack, or may be 
delayed indefinite^. 

Treatment. — The care of these cases is purely symptomatic. 
The child is to be kept very quiet ; ice bags must be applied to the 






542 THE MEDICAL DISEASES OF CHILDHOOD 

head, and the bromide of soda or antipyrin should be given in 
sufficient doses to still the signs of cortical irritation. 

The prognosis depends upon the size of the hemorrhage ; small 
ones are usually not fatal, large ones are commonly so. At the 
beginning of the attack one can never tell how extensive the pro- 
cess is going to be, nor whether it will recur. While we are 
acquainted with this tendency to repeated haemorrhages, never- 
theless we not very rarely see traces of these changes in children 
who died from other causes, and in whom the existence of an old 
pachymeningitis was never suspected until after death, 

It is not always possible to make an exact and prompt diag- 
nosis. When the pachymeningitis occurs in the course of some 
other disease, or without marked pressure symptoms, it is often 
very difficult to differentiate or even to recognize its existence. 
Progressive muscular atrophy and myelitis can usually be barred 
out with no great difficulty. From simple acute meningitis it 
may be distinguished by its more rapid development, quick growth 
of pressure, and little fever. 

Spinal Meningitis 

Inflammation of the spinal meninges generally occurs as an 
extension of a similar process in the cerebral membranes. While 
a direct inflammation of the spinal meninges may possibly be 
caused by trauma, and infection which follows trauma and opera- 
tions, nevertheless, such cases are rare ; and our usual experience 
leads us to expect an involvement of the spinal membranes in a 
fair proportion of the cerebral cases of all kinds. The attacks may 
be acute or chronic ; when the latter is the case, the disease is 
usually located in the dura. 

The symptoms of internal pachymeningitis of the spine are not 
easily dissociated from those of cerebral meningitis. In addition 
to them there will be pain and tenderness along the back, spas- 
modic rigidity in the back, extremities, or chest. If the spinal 
nerves are compressed, there will be corresponding symptoms 
along their distribution ; and if the cord itself feels the pressure 
of the swollen membranes and their exudate, the necessary results 
of interference with movement and feeling may ensue. When the 
pressure is long enough continued it leads to atrophy of the sub- 
stance of the cord. 



^ 



NERVOUS DISEASES 543 

In the acute spinal leptomeningitis the cause is almost always 
dependent upon injury or infection. Here also the possibility of 
extension from a cerebral leptomeningitis is great. The symptoms 
are preceded by those of the active cause. Then there may be 
vomiting or convulsions followed by tenderness along the spine, 
rigidity of the back, flexure of the limbs, and retraction of the 
head. As the medullary substance becomes involved, there may 
be cardiac disability, the respiration may be difficult and often 
assumes the Cheyne-Stokes type. Spastic contractions of the 
muscles, of the rectal and vesical sphincters, will give their charac- 
teristic signs. As the condition is prolonged, paralysis, anaesthesia, 
and contracture may follow the distribution of the nerves whose 
roots are involved. 

In the rare cases that recover, a chronic process is very apt to 
ensue. The symptoms are the natural extension of those in the 
acute form. 

The treatment of all these varieties is symptomatic, excepting 
in the few cases where operation is attempted. 

Syringomyelia 

Syringomyelia, or as it has lately been called, myelosyringosis, 
is a chronic disorder of the spinal cord which is marked by the 
growth of gliomatous or glio-sarcomatous tissue near the central 
canal ; this newly formed tissue breaks down, thereby forming 
cavities. The disease is seen in boys oftener than in girls. While 
any part of the cord or even the adjacent part of the brain may 
be involved, the lesions are generally situated in the upper dorsal 
and lower cervical regions. The cavities vary in number, size, 
and shape, and are filled with fluid; there is a delicate lining 
membrane, outside of which are the gliomatous or glio-sarcomatous 
cells. From the central portion of the cord the new tissue may 
invade the anterior and posterior horns, and the posterior and 
lateral columns. 

The symptoms are focal, and thus follow closely the involve- 
ment of various parts of the cord. The destruction of the 
anterior horns produces muscular paralysis and atrophy, and loss 
of reflexes ; and the parts affected will vary with the location of 
the new tissue. The central gray matter when attacked will give 
vaso-motor symptoms and trophic disorders. When the posterior 






544 THE MEDICAL DISEASES OF CHILDHOOD 

columns are invaded, there will be analgesia and sensory disturb- 
ances. The lateral columns as soon as they are attacked produce 
exaggerated reflexes and stiffness of the legs ; while the posterior 
columns cause incoordinated movements, deficient reflexes, and 
hyperalgesia. In each case the symptoms can easily be deduced 
from the known functions of any segment of the cord, and, vice 
versa, the segment involved can be readily diagnosticated by 
following up the several symptoms to their necessary source. 

Myelosyringosis, which may occur in late childhood, must be 
separated from hydromyelia, which is a congenital dilatation of the 
central canal of the cord. Also it must be distinguished from 
hemorrhage, whose onset is sudden, and tumors. If the new 
growth is syphilitic or tubercular, there will be symptoms of con- 
stitutional disease. In other neoplasms there will rarely be the 
symptoms of more than one diseased locality, the opposite of 
which may exist in myelosyringosis. 

The disease progresses in a series of exacerbations and remis- 
sions which are irregular in intensity and length. The final 
prognosis is bad, but there is no known method of influencing 
the disease, outside of symptomatic and general care. 

Myelitis 

The fact that inflammation of the cord is very rare in patients 
under the age of puberty, and that there is a noticeable sameness of 
the disease as it occurs in children and adults, make an extended 
account of it unnecessary. It may follow the severe infectious 
diseases, Pott's disease, or injury, and doubtless has in some cases 
an infectious nature. Its course may be acute, sub-acute, or 
chronic. 

Lesions. — The dorsal region is most often attacked, and the 
process may be transverse, disseminated, or diffuse. The affected 
part is congested and swollen, and one cannot plainly see the 
distinguishing characteristics between the gray and white parts. 
The consistency of the cord has changed and become soft; in 
such areas one may see dilated vessels, leucocytes, granules of 
myelin, and corpora amylacea. When a recent haemorrhage has 
taken place, the color of the softened part is red, but with the 
passage of days the red changes into yellow. The softness varies 
in different cases from a slight degree to one of fluidity. As the 



NERVOUS DISEASES 5±5 

result of secondary changes, the tracts in the cord will be involved 
upward and downward, according to the direction in which 
their impulses are directed. 

Symptoms. — The beginning of the disease is usually steady 
and gradual. As the lesions develop, the symptoms naturally 
follow their location. Complete transverse myelitis causes impair- 
ment of motion and sensation, disorders of rectal and vesical 
functions, and disturbed reflexes. If the cervical part of the cord 
is attacked, there will be paralysis of the upper and lower extremi- 
ties, the first stage of which is flaccid, the second spastic. Anaes- 
thesia exists in all four limbs as well as in the body as far down as 
the plane of the lesion. In addition there may be disorders of the 
pupil and unilateral vaso-motor disturbances. In dorsal lesions 
the arms are not affected, the lumbar region is attacked by 
secondary degeneration, and the eyes are not involved. With an 
affection of the lumbar region, the arms and legs are paraplegic 
and anaesthetic ; rectal and vesical sphincter control is impaired, 
and knee reflex is lost. An indication of the diseased locality 
is the distribution of anaesthesia ; these areas must correspond to 
the parts that are supplied by nerves which lead off below the level 
of the lesion. At the superior margin of the anaesthetic area a 
zone of hyperesthesia exists. In some cases there may be a 
distinct girdle sensation which defines the boundary line between 
the healthy and abnormal sections. 

The affected muscles show the reaction of degeneration ; invol- 
untary spasmodic twitchings are almost universal, and trophic 
-disturbances, in the form of bed-sores, are common. There may 
he disturbances of temperature, but they are quite atypical, vary- 
ing according to the pathological processes which are present in 
each case. 

When the myelitis is disseminated or diffuse, there will be a 
mixture of the localizing symptoms according to the parts involved. 
The process in practically all cases is slowly progressive, and as 
the acute form changes into the sub-acute and chronic the tem- 
perature falls, complications of various sorts ensue, and the 
patient may finally die from their action or that of the original 
inflammation. 

Treatment. — The care of these cases is largely general and 
symptomatic. Where there is a known preliminary disease it 
naturally must receive its full share of attention. 
2n 



546 THE MEDICAL DISEASES OF CHILDHOOD 

The inflammation of the spinal cord calls for complete rest 
in bed, the clearing of the intestinal canal by means of calomel 
and a saline, the administration of nutritious and easily digested 
food, and the careful catherization of the bladder. The various 
symptoms as they appear must be wisely attended. Ice bags may 
be applied to the back, and mild counter-irritation may be used, 
but always with the thought that it may easily start an obstinate 
irritation of the skin and trophic disturbances of serious import. 
Such drugs as potassium iodide and ergot have in past times 
been recommended, but no good need be expected from them. 
It is possible that surgical means may be found to open the verte- 
bral-canal, wash it out, and so reduce in part the inflammation as 
well as the amount of exudate. 

The prognosis in these cases is bad ; a few mild cases recover, 
but usually leave behind them permanent traces of their former 
presence. The sub-acute and chronic cases usually die from 
exhaustion or intercurrent disease. 

Differential Diagnosis. — The diagnosis may be made from the 
slow and steady unfolding of the symptoms, the permanent nature 
of the anaesthesia, disturbed rectal and vesical control, and the 
atrophy and flaccidity of the muscles at the level of the lesion, 
combined with spastic contraction of those below that leveL 
Usually it is not difficult to distinguish myelitis from spinal 
meningitis, for the latter is very rare unless it occurs with cerebral 
meningitis or trauma, and is marked by pain in the affected region 
as well as some degree of neuralgia in the nerves of its distribu- 
tion. Haemorrhage may be marked off by its very sudden onset, 
its great and immediate pain, possible lack of fever, and the gradual 
abatement of symptoms as the effused blood is absorbed. 

Compression of the Spinal Cord 

This condition, synonymously called compression myelitis and 
Pott's paralysis, is the result of pressure upon the cord and its- 
membrane by caries of the vertebrae, injuries, tumors, and aneu- 
rism. In the large majority of cases tuberculosis of the vertebrae 
is the active cause. 

Lesions. — The bones enter upon a course of tubercular degen- 
eration which may involve the intervertebral cartilages. As the 
result of the weight contributed by the parts above, the spinal 



NERVOUS DISEASES 547 

curve is broken, and a displacement to the rear is produced. The 
cord is caught in the narrowed channel, which is made still nar- 
rower by the accumulation of the products of inflammation in 
front of the cord. The cord is somewhat cedematous, its color 
becomes pink or reddish gray, and the differentiation between the 
white and gray matter is gradually lost. The dura mater is com- 
monly involved, so that a synchronous pachymeningitis takes 
place. In the cord there is an increase in the interstitial tissue, 




Fig. 118. — Compression of the Spinal Cord : Degeneration of Descending Columns. X 25. 

(The light portions represent the spreading degeneration.) 



a cellular proliferation, and a progressive degeneration of nerve 
elements. Outside of the tissue directly affected, there will be 
ascending and descending degeneration, and the peripheral nerve 
roots will naturally respond to the degree of strain and irritation 
that is put upon them. 

Symptoms. — The signs of the disease may not show them- 
selves until some time after caries begins; and on post mortem 
examination one may be surprised at the comparatively small 
amount of disturbance which the pressure has caused. The 
symptoms are generally referred to the cervical and dorsal regions, 
where tuberculosis of the vertebrae is usually found. From the 






548 THE MEDICAL DISEASES OF CHILDHOOD 

parts involved pains will start, following the distribution of the 
various nerves. Hyperesthesia of the surface is often the pre- 
cursor of anaesthesia ; and with this condition there is a gradually 
increasing spastic paralysis of the legs, or of the legs and arms. 
Contractures are not common. The inflammation may now spread 
from the point of pressure, and gradually take on the character 
of a myelitis; in fact this is the usual course of development, 
whether the lesion is originally unilateral or bilateral. In this 
event the picture will finally merge into that of a myelitis of the 
ordinary type with atrophy, contractures, loss of rectal and vesical 
control, and bed-sores. Among the rare manifestations of the dis- 
ease are paralysis of the diaphragm, irritation of the phrenic nerve, 
gastric and pupillary disorders. 

Treatment. — The general care of the child is very important. 
Diet, hygiene, and sanitation must be of the best. The child 
should be confined to bed, and as soon as the acute symptoms 
have passed, he should wear a plaster of Paris jacket. As this 
remedy indicates, relief from the pressure is one of the main 
objects desired. Tonics should be administered in order to help 
nature in the conservative effort to throw off the disease. Other 
means, such as counter-irritation, ergot, and potassium iodide, have 
been used ; but their value is doubtful. 

A logical method consists in surgical measures that are devised 
to take away the diseased bone. While the attempts have hereto- 
fore not been successful, nevertheless they should not be aban- 
doned ; and although children bear operations upon the skull and 
spine poorly, the only real hope of permanent improvement lies in 
such radical measures. At the same time it is only fair to state 
that surgeons do not regard the operation favorably, because it is 
apt to be so difficult and dangerous. 

Prognosis. — Each case must be judged by itself. If treatment 
is promptly begun and pressure removed, a favorable, outlook is 
not unusual. The farther the symptoms have developed, the 
poorer are the chances of recovery. Nevertheless, at any stage 
of the disease hopes for betterment should always be entertained. 
Death may occur from exhaustion, from medullary irritations of 
an extreme degree, from dislocation of the odontoid processes, or 
from intercurrent disease. 

Differential Diagnosis. — The existence of no other cause than 
the fact of or the predisposition to tuberculosis, the gradual course 



NERVOUS DISEASES 549 

of the disease, the weak spot in the spine with or without kyphosis, 
the vertebral stiffness, radiating pains, and increased reflexes, mark 
off compression of the cord from myelitis. The fact that the 
latter disease may be a sequel to the symptoms mentioned above 
will render confusion not unusual. 

Infantile Spinal Paralysis 

This disease is known as infantile spinal paralysis, acute ante- 
rior poliomyelitis, and the essential paralysis of children. It 
occurs more frequently in warm than in cold weather, and attacks 
boys oftener than girls. In the majority of cases the patients are 
under five years of age, the largest number being in the second 
year. Its causation has in the past been attributed to a wide 
variety of unfavorable conditions, which in the last analysis we 
may regard as coincidental rather than aatiological. On the other 
hand, observation of a large number of cases scattered over sev- 
eral years tends to convince one that the origin of the disease is 
purely infectious, that it may occur in epidemics, and that the 
true aetiology must be sought in some specific micro-organism or 
poison. 

Lesions. — The cord is commonly attacked in the lumbar or 
cervical regions, and the changes may be confined to these parts, 
or may be scattered irregularly over a considerable extent of tis- 
sue. The anterior gray horns bear the brunt of the attack, and 
in them the ganglion cells undergo shrinkage, pigmentation, 
degeneration, and atrophy. The same processes may by exten- 
sion involve the gray and the white matter, the anterior and 
lateral columns. In these parts, as well as in the anterior horns, 
there may be a deposition of connective tissue that helps to 
change the normal form and cause depressions and pittings. The 
peripheral nerves, w T hich lead off from the involved cornua, show 
similar degenerative changes, but their destruction is usually 
incomplete. Likewise the muscles that are supplied by the 
affected cornual cells undergo a process of atrophy by which they 
lose their structure, and in extreme cases are turned to fibrous 
bands in which there may be a fat-infiltration. Even the bones 
to which the paralyzed muscles are attached show the effect of 
the paralysis. They are smaller, thinner, and weaker than they 
normally would be ; but this change comes, doubtless, from the 
inability of the muscles to provide exercise. 



550 THE MEDICAL DISEASES OF CHILDHOOD 

Symptoms. — Very often the disease begins as any other acute 
infectious disorder, but without recognized prodromata. In two 
cases I obtained a history of an initial chill ; then one may be told 
of a sudden rise of temperature, projectile vomiting, sometimes of 
convulsions and coma. The parts that are to be paralyzed are 
generally painful, but the amount of pain varies within consider- 
able limits. The variations in severity of all these symptoms are 
considerable : the convulsions may or may not be repeated, the 
vomiting may be trivial or alarming, the temperature may rise 
only a little above normal or may reach 40° C. (104° F.). These 
acute symptoms may last for as short a time as a day, or may be 
prolonged until a week has passed. A dysarthria may be present 
that may easily be mistaken for a partial aphasia. From the first 
hours of the sickness one may recognize the paralysis in limbs or 
body ; generally, however, the strain and stress of the acute onset 
draw the attention from the muscles, and the paralysis is not 
noticed until these acute symptoms have passed. 

The paralysis now remains as the principal feature of the dis- 
ease. Often it bursts out in a stormy manner which after a few 
days spends its force, leaving certain parts more or less perma- 
nently affected. This paralysis may be denominated flaccid ; the 
parts become atrophied, their reflexes fade away to a greater or 
less extent, and the electrical reactions are those of degeneration. 
The final paralyses may be situated in various parts of the body, 
but certain ones are more commonly affected than others. The 
left leg is the favorite seat of the disorder, followed in frequency 
by the right leg ; a leg and the opposite arm are a fairly common 
combination; while all four extremities, both legs and both arms, 
are much more rarely affected together. Involvement of the 
trunk muscles is not often seen. The extensor muscles of the leg 
are oftener attacked than the flexor, and in the hand and forearm 
a similar rule holds good. As a result, the deformities which we 
usually see are of the type of drop-foot, talipes equinus, equino- 
varus, or valgus, flexed knee, and flexed thigh. Flexion of the 
wrist and fingers is seen, and occasionally a subluxation at the 
shoulder joint follows deltoid atrophy. Deformities of the back 
and spinal cord may occur, particularly lateral curvature. 

Treatment. — The treatment of the acute stage is that of all 
acute infectious diseases ; rest in bed, free catharsis, regulation 
of food, promotion of hygiene and sanitary conditions. Seda- 



NERVOUS DISEASES 551 

tives may be needed to control vomiting, convulsions, and pain. 
As soon as this stage has passed, the principal care relates to the 
prevention and cure of deformities. For this purpose one obtains 
the best results from passive motion and massage, while the bene- 
fits to be derived from the commonly employed electricity are 
doubtful. The main object is to develop whatever muscles or 
muscle fibres that are left to their best degree of utility. As soon 
as the child is able to be about, systematic exercise with chest 
weights, dumb-bells, and the bicycle must be used under skilled 
supervision. Tonics are generally indicated, such as iron and 
strychnine ; but the latter must be prescribed in small doses to 
avoid the danger of over-stimulation. Orthopaedic splints may 
be of much use in the presence of deformities. In some cases 
tendon grafting has been done with good results. 

Prognosis. — During the acute attack no reliable judgment of 
the ultimate outcome can be regularly formed. One should 
remember that after the first flurry there is a period of rest, fol- 
lowed by some improvement before the permanent paralysis 
becomes established. In this way one is fairly safe in believing 
that the final condition will be better than the initial appearance 
would warrant. The appearance, extent, and duration of the 
reaction of degeneration — a failure to respond to f aradic stimu- 
lation and a changed galvanic reaction, so that anodal closure 
contraction equals or exceeds the cathodal closure contraction — 
will give the best idea of the child's future condition. One must 
remember that the condition may gradually improve, especially 
with proper developmental care, during the first six months or 
year. Danger of death is so small that it need not be seriously 
considered. 

Differential Diagnosis. — The main facts to be kept in mind 
are the acute onset, the periods of rest and improvement, followed 
by permanent paralysis, the lack of sensory disturbances, reaction 
of degeneration, and atrophy of the paralyzed muscles. These 
facts will mark off the disease from any form of meningitis with 
its marked cerebral symptoms ; transverse myelitis, with its anaes- 
thesia, exaggerated reflexes, deficient sphincter control, normal 
electrical reaction, and trophic disturbances, will likewise be 
excluded ; cerebral paralysis gives a picture of spastic instead of 
flaccid paralysis, contractures, normal electrical reaction, disturbed 
intellectual faculties, epileptic tendency, and a disposition to hemi- 



552 THE MEDICAL DISEASES OF CHILDHOOD 

plegia ; multiple neuritis seldom simulates anterior poliomyelitis, 
since it gives sensory symptoms, a history of slow growth and 
previous disease, pain along nerve branches, and shows a tendency 
to disappear after a few weeks or months. Occasionally confu- 
sion has been caused by the muscular disabilities of rickets and 
scurvy ; but here the systemic condition alone, even if we omit 
the important factor of normal electrical reaction, is sufficient to 
define the disease. 

Multiple Neuritis 

Causes. — Multiple neuritis, also called polyneuritis, designates 
those pathological conditions in which disease of various nerves, 
related or unrelated, cause the various symptoms. This disease 
is the result of some form of poisoning, such as the toxines, or 
tox-albumins generated in the acute infectious fevers (of which 
the most prominent is diphtheria, followed by such others as 
enteric fever, smallpox, scarlet fever, measles, malaria, tuber- 
culosis, syphilis), by various micro-organisms, beri-beri, exposure 
to cold, alcohol, and the metallic poisons, arsenic, lead, mercury, 
and phosphorus. 

Lesions. — The process is a degeneration of the nerve fibres ; 
there are congestion and swelling of the nerves, and an exudation 
of serum and fibrin. The fibrillar nuclei are enlarged, the con- 
nective tissue between the nerve elements proliferates, and round 
or spindle-shaped granular cells may be seen about the sheath of 
the nerve. The process is not alike in all areas ; in some the 
inflammation is interstitial, in others it is parenchymatous. Only 
in rare cases is the perineurium involved. While the changes 
are confined to the peripheral nerves, not all parts of them are 
affected with equal facility, and the farther removed a part is 
from the mother cell the more readily does it become affected. 
The fact that there may be associated degeneration of ganglion 
cells in the cord does not necessarily bear any rigid relation to 
the changes in the nerves. 

Almost any part of the body may be affected, but in children 
we most commonly meet disorders of the anterior tibial, musculo- 
spiral, and peroneal nerves, or stated more broadly — the exten- 
sors of the wrist and feet. 

Symptoms. — The disease may begin in an acute flurry, but 
usually the onset is gradual, so that one, two, or three weeks 



NERVOUS DISEASES 553 

elapse before a full development of the signs. The main symp- 
toms consist of motor and sensory paralyses, both being symmet- 
rical and having the same distribution. The affected muscles are 
flaccid, begin soon to atrophy, and in proportion to the degree of 
wasting show the reaction of degeneration. Although any part 
of the body may be affected, nevertheless the disease so often 
settles in the extensors of the wrist and foot that the resulting 
drop-wrist and drop-foot are almost characteristic of the disease. 
With the motor paralysis there is a decrease of sensation accom- 
panied in many cases by pain along the course of the nerve. The 
parts winch are farthest removed from the centre are the first to 
suffer, and one of the initial signs is the inability while standing 
with the flat of the foot on the ground to raise the toes. From 
the extremities the paralysis works its way upwards until almost 
all the muscles may be disabled and atrophied. In unusually severe 
cases the trunk and neck may likewise be involved, so that finally 
the child is absolutely helpless. Even in the milder cases there 
will be diminished reflexes, tremor, incoordination, and the pres- 
ence of Romberg's symptom (inability to stand erect and firm 
when the eyes are closed). The development of these symptoms 
is not absolutely fixed in time, and they may be among the first 
or the later manifestations of the disease. 

In the first part of multiple neuritis normal sensation may 
change to hyperesthesia, which in turn gives way to anaesthesia. 
This sensory disturbance may be complete, including the tempera- 
ture, touch, muscular, and pain senses. On the other hand this 
impairment may, like the motor paralysis, vary in degree. Vaso- 
motor changes are commonly seen, producing a shiny and puffy 
condition of the skin. A characteristic sign when the hand is 
affected is the gradual tapering of the fingers to a noteworthy 
extent. Another important diagnostic point is the normal con- 
dition in which the rectal and vesical sphincters are allowed to 
remain. 

The form of multiple neuritis which follows diphtheria is com- 
mon and important enough to require special mention. It may 
follow any degree of infection, from the slightest to the pro- 
foundest, although the latter is the more frequently seen in this 
connection. It rarely occurs in infants ; and when it does break 
out two or three weeks usually intervene between it and the 
diphtheritic infection. In most cases the palate is the first part 



554 THE MEDICAL DISEASES OF CHILDHOOD 

to be attacked, and its involvement produces regurgitation of 
liquids through the nose, and nasal speech. Inspection of the 
throat will enable one to notice the loss of the normal curve of 
the soft palate, and the flaccid manner in which it hangs from its 
attachment. Sometimes the paralysis is not confined to this part, 
but may invade the throat, face, the extremities, and thorax. 
Affection of the third nerve produces ptosis, of the sixth produces 
inability of the rectus externus ; in addition there may be stra- 
bismus and dilatation of the pupils. The pharynx and larynx 
may also be attacked, the latter giving the symptoms of severe, 
choking cough and patent glottis during the act of swallowing. 
When the laryngeal muscles and the vocal cords are partly dis- 
abled, there will be imperfect tone production and hoarseness. 
When the paralysis spreads to the thorax, the muscles of respira- 
tion, the diaphragm, and the heart may be affected. The resulting 
respiratory symptoms are progressive attacks of subjective and 
objective dyspnoea, and thoracic breathing. The cardiac signs 
are weak and disturbed beat and pulse, which may precede paraly- 
sis of the heart muscle. 

In other respects the paralysis of diphtheria is the same as the 
general type of multiple neuritis. 

A third form, that, on account of its isolation, is worthy of 
special mention, is the so-called facial or Bell's paralysis. It may 
occur after exposure, with acute or chronic ear disease or neigh- 
boring disorders, and as a symptom of disease at the base of the 
brain ; the facial nerve will thus have been respectively affected 
after it emerges from the skull, in the bony canal, and within the 
skull. The muscles about the forehead, the cheeks, eyes, nose, 
and mouth will be more or less influenced. As a result there is 
lagophthalmos which cannot entirely be overcome, inability to 
elevate the affected side of the nose, flaccid condition of the cheek, 
and imperfect success in puckering or raising the lips. Attempts 
to close the involved lids are not successful, and in addition cause 
a straining of the corrugator supercilii and frontal muscles of the 
other side ; if the child tries to display the teeth, the whole mouth 
is pulled away from the paralyzed side, and if the tongue is pro- 
truded it inclines in the same direction. There are no sensory 
disorders, and the electrical reactions are changed in correspond- 
ence to the degree of paralysis. 

Treatment. — The care of these cases is, on the whole, general ; 



NERVOUS DISEASES 555 

there is no specific remedy at hand, and, indeed, in most cases 
none is needed. Whenever the cause or precedent pathological 
condition can be distinguished, it should if possible be removed. 
Since the tendency of the disease is toward recovery, our atten- 
tion should be directed toward the general care of the child, his 
hygiene and sanitation, the proper regulation of his food, the 
proper control of his excretory organs. Special symptoms, such 
as pain and restlessness, may be controlled by heat and sedatives ; 
and in most cases general tonics are indicated. As a general rule 
the use of passive motion and massage is of decided benefit ; and 
occasionally some sort of orthopsedic splint may be required to 
give support to exhausted parts of the body. In the heart failure 
of diphtheritic neuritis the patient is soonest relieved by hypoder- 
matic injections of small doses of morphine with or without strych- 
nine. And for treatment of the respirator}" paralysis the faradic 
current has been much commended. In laryngeal paralysis the 
danger of inspiring food requires that the child be fed by means 
of nutrient enemata, or through a tube which is put into the stom- 
ach by way of the nostrils and oesophagus. If the laryngeal paraly- 
sis is so slight as not to interfere with the ordinary manner of 
eating, the food should be solid rather than fluid. It goes with- 
out saying that all complications should receive their requisite 
treatment. When improvement has once set in, the continued 
use of strychnine or nux vomica combined with an organic prepa- 
ration of iron is likely to give good results. 

Prognosis. — In most cases the outlook is good. The paraly- 
sis begins, becomes worse, and then improves — all within a few 
weeks. Most cases recover completely, although there are a few 
where a part or the whole of the original paralysis remains. In 
those forms where the laryngeal and throat muscles are involved, 
particles of food may be inspired into the lung with a fatal 
result. Involvement of the respiratory and cardiac muscles 
usually signifies a severe form of the disorder with a compara- 
tively large mortality. In all these conditions the general health 
is more or less undermined, and intercurrent diseases, which are 
sometimes fatal, are easily contracted. The amount and persist- 
ence of the reaction of degeneration is a good index by which to 
judge of the probable permanence of the disabilities. 

Differential Diagnosis. — The history of the cause or antecedent 
pathological condition may turn one's attention to the possibility 



556 THE MEDICAL DISEASES OF CHILDHOOD 

of multiple neuritis. When the characteristic features of the 
disease appear, the diagnosis is usually not difficult. These 
features are the gradual beginning of the neuritis, the great area 
over which the lesions may be distributed, the coincident occur- 
rence of motor and sensory disturbances in time and locality, the 
development of wasting in the paralyzed muscles, and the partial 
or complete electrical reaction of degeneration. 

Progressive Muscular Atrophies 

This heading includes a group of disorders the rationale of 
which is not as yet entirely known. They all have a common 
feature of steadily increasing weakness and final atrophy of certain 
muscles. Some of them have their origin in abnormal conditions 
of the cord, and are called amyotrophies ; others begin with disease 
of the muscular system and are called myopathies. Of the amyo- 
trophies the main variety is known as progressive muscular atro- 
phy, or the Aran-Duchenne type, so called after the men who first 
described it. The principal variety of myopathies is called mus- 
cular pseudo-hypertrophy, and its subdivisions are called after 
the anatomical distribution of the hypertrophy and atrophy. The 
causes of these diseases are not known, and how much importance 
should be laid upon their occurrence in family lines is hard to 
say. So little is positively known about the lesions that the best 
course until fuller information is obtained is to leave the matter 
untouched. 

The Aran-Duchenne type of progressive muscular atrophy 
attacks the hand. The thenar and hypothenar muscles are first 
attacked, followed by the interossei, the flexors, and extensors of 
the forearm. Contractions naturally result, and form what is 
known as the claw-hand. If the process continues, it slowly 
involves the flexors of the upper arm, the triceps, the deltoid, the 
muscles of the shoulder, back, and trunk. According to Duchenne 
the disease may sometimes begin in the inverse order, or even in 
the legs. One of the first symptoms is a fine fibrillary contrac- 
tion in the muscles affected ; added to this is a moderate degree 
of change in the electrical reactions. Progressively the atrophy 
becomes more and more pronounced until the patient is quite dis- 
abled. The disease is incurable, but may allow the patient to 
live for years, until exhaustion, intercurrent disorders, or even an 



NERVOUS DISEASES 557 

unusual atrophy of the muscles of the neck, which interferes with 
breathing and swallowing, puts an end to life. 

The peroneal form of progressive muscular atrophy, known 
also as the Charcot-Marie-Tooth type, and called by Sachs pro- 
gressive neural muscular atrophy, usually attacks the extensor 
muscles of the toes, spreads to the small muscles of the feet, and 
then works its way upward from one to another, after the fashion 
of the disease in the arm, until the whole leg may become involved. 
A later extension may in a few cases finally involve the hand and 
forearm. In this peroneal form contractures occur, and form pes 
equinus, pes equino-varus, and club-foot ; sometimes the disease is 
bilateral, and thus produces a double club-foot. Sensory changes 
may occur, and the reflexes are lessened or abolished. In most 
cases the reaction of degeneration is present in the affected 
muscles in proportion to the degree of atrophy. On the whole, 
the wasting is not so marked as in the hand type. 

Muscular pseudo-rrypertrophy is usually found in early child- 
hood. Boys are more frequently attacked than girls, but the 
inheritance is almost always from the mother. At the beginning 
an increasing weakness is seen in the legs, followed by an increased 
size of the calf ; in exceptional cases the increase may start in the 
muscles of the thigh. The child has a clumsy, waddling walk, 
and on account of his weakness is partially disabled from climb- 
ing stairs, or accomplishing similar acts. In some late cases there 
may be an associated pseudo-hypertroph}' of parts of the upper 
extremity. The weakness of the hypertrophied muscles finally 
becomes so extreme that the child becomes absolutely helpless. 
Finally there may be an atrophy of the thigh, arm, and shoulder 
muscles. There will generally be signs of degeneration : reflexes 
are diminished, there is a lessened response to faradic stimulation, 
there may be nystagmus and some feeble-mindedness. The course 
of the disease is chronic, irregular, and usually ends in death. 

Erb's type — the so-called juvenile form of progressive mus- 
cular atrophy — attacks children or youths in the liianner of a 
continued atrophy of some of the shoulder, upper arm, pelvic, 
thigh, and back muscles. After the lapse of a considerable period 
the muscles of the leg and forearm may likewise become involved. 
In conjunction with the atrophic process there may in some cases 
be a real or pseudo-hypertrophy of certain muscles, such as the 
deltoids, supraspinati, and infraspinati. These stand out very 



558 THE MEDICAL DISEASES OF CHILDHOOD 

plainly in contrast to the withered pectorals, latissimi dorsi, tra- 
pezii, serrati, and rhomboids. The condition is sharply marked 
off from the previous types by the absence of the reaction of 
degeneration, fibrillary contractions, sensory and visceral dis- 
orders. The type is rare and its course is long. 

The Landouzy-Dejerine type — the facio-scapulo-humeral form 
— is seen in very young children. The face is first attacked, and 
on account of the atrophy in all the muscles excepting those 
about the mouth the lips project, may become hypertrophied, and 
thus make the deformity of "tapir-mouth." From the face the 
atrophic process may spread to some of the muscles of the shoulder 
and arm ; but the flexors of the hands and fingers, the subscapu- 
lars, the supraspinal, and infraspinati are not involved. 

The treatment for all these conditions is indefinite. The gen- 
eral care and nutrition should be made as good as possible ; in 
most cases the patient should be confined to bed, and given the 
benefit of massage and passive motion. If he improve enough to 
warrant greater exertion, carefully regulated exercise may be pre- 
scribed. General tonic mixtures may be indicated. Sachs believes 
in the early and thorough use of orthopsedic appliances. Under 
any circumstances the outlook is not very encouraging. 

Hereditary Ataxias 

Under this head are included hereditary spinal ataxia, com- 
monly called Friedreich's disease, hereditary cerebellar ataxia, or 
Marie's disease, and ataxic paraplegia. These were originally 
included in locomotor ataxia; but careful observation has demon- 
strated the separate identity of each. One of the main character- 
istics of all, is the fact that they occur in families. Any other 
cause is at all events doubtful. The occurrence of previous in- 
jury or acute disease cannot be regarded as more than coinci- 
dence. 

Friedreich's Disease. — In hereditary spinal ataxia there is a 
degeneration or lack of development in the columns of Goll, the 
columns of Burdach, and the pyramidal tracts. In the columns of 
Goll the whole area is affected; in the columns of Burdach all except 
the column of Lissauer may be irregularly involved ; and the pyra- 
midal tracts may be also entirely changed. The lesion consists of a 
diffuse sclerosis. The first symptom is an incoordination of mus- 



■■ 



XERVOUS DISEASES 559 

cles joined to weakness of the extremities. In the legs this produces 
an ataxic gait; in the arms it causes inability to perform finely 
adjusted movements, such as writing, drawing, and carving. In 
addition there may be involuntary choreic movements that result 
from efforts to balance the body. There will also be some inco- 
ordination of the muscles which are concerned in speech and 
articulation, so that the former is arhythmic, unchanging in pitch, 
often nasal, while the latter is jerky and syllabic. Gradually the 
reflexes become diminished, and finally are altogether absent. As 
the patient tries to balance himself, the extensor tendons of the 
toes may be seen to relax and contract. This is all the more 
noticeable when the disease is so far advanced that the character- 
istic deformity of the foot has developed. This deformity con- 
sists of an over-extension of the first and second toes, and a 
cupping of the arch, the result of which is very much like pes 
cavus. Simultaneously there will be a lateral or rotatory curva- 
ture of the spine. When the lesions have advanced far enough 
to attack the medulla oblongata there will be a gradual develop- 
ment of dizziness, fainting, tachycardia, and sharp, neuralgic pains. 
In some cases there may be lateral or rotatory nystagmus. 

The course of the disease progresses steadily toward death, 
and may last from ten to fifteen years. There is no special 
treatment excepting massage, passive movements, and exercise. 

Marie's Disease. — In hereditary cerebellar ataxia there are 
hypoplasia and degeneration in the cerebellum, which may de- 
crease so much in size that its bulk is reduced one-half, or so 
little that the change is barely noticeable. The cells of Purkinji 
are much reduced in size and number, while there may be a 
simultaneous increase in the neuroglia. The symptoms begin 
with incoordination of the upper and lower extremities, on ac- 
count of which the arms become more and more useless, while the 
legs acquire the ordinary cerebellar gait. While the progress of 
the muscular inability is steady, it may nevertheless be slow. The 
patient in walking assumes a characteristic attitude : the upper 
part of the body is bent, the chin is held out and up, the head 
is thrown back, the widely planted feet and the staggering gait 
go to make a striking picture. A noteworthy and logical fact 
becomes evident when the patient lies down; then the incoordina- 
tion of arms and legs practically vanishes, and he is able to make 
movements that were quite impossible in the erect posture. As 



560 THE MEDICAL DISEASES OF CHILDHOOD 

the disease progresses, the muscles which are concerned in speech 
and articulation become affected, so that the pitch is monotonous, 
the rhythm faulty, the tone nasal, and the pronunciation jerky and 
syllabic. In many cases the movements of the eyes show a 
weakness of the external recti muscles, but there is no nystagmus. 
Ophthalmological examination sometimes shows an optic atrophy 
and progressive choroiditis. The reflexes are regularly increased, 
particularly in the knees. One of the main characteristics is the 
gradual loss of mental power, especially the faculties of association 
and memory. A remarkable fact that is not infrequently seen is 
a flattening of the skull over the cerebellum, which doubtless 
follows the decrease in size of the hind brain. 

Hereditary cerebellar ataxia may continue for several years 
before exhaustion or intercurrent disease puts an end to it. The 
treatment is symptomatic and general ; attention should be paid 
to massage and passive movements. 

Hereditary ataxic paraplegia, described by Dana, is a condi- 
tion that attacks children at about the age of puberty. There 
are, evidently, a hypoplasia and degeneration of the lateral 
columns and some of the peripheral and central neurons. The 
changes affect consecutive levels of the cord until the medulla 
oblongata is attacked. The course of the disease is progressive 
with remissions. The first symptom is a clumsy, awkward 
manner of walking that gradually becomes exaggerated into a 
typically ataxic, paretic gait. Later on there is a similar affec- 
tion of the upper extremities which ends in thorough incoordina- 
tion. A noteworthy fact that differentiates this disorder from 
hereditary cerebellar ataxia is that the incoordination persists in 
the reclining as well as the erect posture. The reflexes gradually 
become exaggerated, most of all in the lower extremities. After 
a variable time the feet assume the cuplike deformity that is 
regularly seen in hereditary spinal ataxia, and the hands become 
crooked ; this latter deformity consists of a flexure of the first and 
second phalanges, and a slight extension of the terminal phalanx. 
The eyes are gradually involved : early in the disease there is a 
beginning optic atrophy, and later on there may be nystagmus, 
paralysis of the external recti muscles, and partial paralysis of the 
lids. The throat muscles likewise become involved, and give rise 
to difficulty in swallowing, phonation, and articulation. Sphincter 
control is deficient in the later stages, the muscular sense is lost, 



NERVOUS DISEASES 561 

complete paraplegia supervenes, and a fatal result is then merely 
a question of time, accident, or intercurrent disease. 
The treatment is general and symptomatic. 

Acute Ascending Paralysis 

Acute ascending paralysis, called Landry's paralysis, is so 
rarely seen in children that no more than a mention of it is 
required. Its cause is unknown, and its lesions are extremely 
obscure. Various inflammations of the cord have been found 
after death, but they are so irregular and so inconstant that no 
reliable connection between them and the disease can be made. 
The symptoms may begin with disturbances of pyrexia ; then, 
more or less rapidly, the paralysis sets in. It begins in the feet, 
and gradually works its way through the legs, body, neck, and 
face. Each part as it becomes involved gives its particular symp- 
toms. The muscles are flabby and weak, and as those in the abdo- 
men become affected there will be constipation ; as those of the 
diaphragm become attacked, there will be a corresponding diffi- 
culty in breathing ; as those of the larynx and throat become 
involved, there will be impaired power of phonating, articulating, 
and swallowing ; as those of the eyes become disabled, there will 
be paralysis of the lids. Sensation is progressively lost, sphincter 
control impaired, and electrical reactions changed. 

The course of the disease is short, and usually ends in death. 
Some cases have, however, recovered ; in that event the arms are 
the first to recover their function. 

The treatment is symptomatic and general. 

Infantile Cerebral Paralysis 

This group of cases represents, in varying degrees of paralysis, 
some injurious impress on the brain. They occur at any time of 
life — before, during, or after birth. According to the part of the 
brain which is affected, there may be a hemiplegia, a double hemi- 
plegia or diplegia, a monoplegia, or a paraplegia. The disease 
occurs somewhat oftener in boys than in girls, although it is 
impossible to state a reasonable cause for the preference. The 
paralysis is the most prominent, but not necessarily the only or 
most important, symptom of the disease, and thus gives a name to 
the whole group. 
2o 



562 



THE MEDICAL DISEASES OF CHILDHOOD 



Causes. — Intra-uterine cases may be due to injuries, infec- 
tive and serious diseases from which the mother suffers, and the 
many obscure conditions in which the equilibrium of nutrition is 
seriously disturbed. Among the active causes of such disturbance 
may be systemic or constitutional disease, marked weakness, dis- 
turbed functional activity, and psychical shock and strain. The 
arrests of development which result are frequently very obscure 
in their setiology. The cases that occur during labor are the 
result of slow and difficult expulsion of the foetus, due to its large 









Fig. 119. — Organizing Thrombus in Vein. X 10. 



size, absolute or comparative, to malposition, to premature rup- 
turing of the membrane, or to atonicity or pathological inability 
of the mother to complete the labor. The extra-uterine or ac- 
quired paralyses are due to injury, the infectious diseases, constitu- 
tional disease, psychical shock, convulsions, apoplexy, and epilepsy. 
Lesions. — We know more about the results than the process 
of the pathological changes. Thus in the intra-uterine cases the 
process is one of arrested development, with a resulting absence 
of certain elements of normal brain equilibrium. In the paralysis 
of parturition the main process is meningeal and cortical hasmor- 



NERVOUS DISEASES 563 

rhage, or bleeding from a venous sinus, with resulting pressure, 
atrophy, cyst formation, sclerosis, or porencephalia. In acquired 
paralysis there may be apoplexy, embolism, thrombosis, and fatty 
degeneration, with their consequent loss of tissue and function. 

Haemorrhage is usually the beginning, and is commonly fol- 
lowed by convulsions, with or without coma. Since the lesions 
are for the most part located in the cortex, the effect may be 
expected to produce a prompt effect upon the body. Accord- 
ing to the localities involved there may be a hemiplegia, a 
diplegia, a paraplegia, and rarely a monoplegia. With any of 
these conditions there may be strabismus. In the majority of 
cases there is a variable amount of rigidity and contraction in the 
paralyzed muscles. As a result there ma}' be a large degree of 
deformity. Thus, in the face the affected side may seem pulled 
down and flattened, and the normal folds are diminished or 
absent ; or the arm may be drawn to an angle, and the fingers 
more or less flexed ; in the thighs spasms of the adductor muscles 
may cause cross-legged progression, and in the feet talipes equinus 
and talipes equino-valgus may occur. Frequently the muscles are 
flabby and weak instead of rigid. 

The affected part loses not only in function, but also in its 
growth in all dimensions. It is undersized, and seems rightfully 
to belong to a younger child. While it undoubtedly does grow, 
nevertheless the degree is much smaller than that of the unin- 
volved parts. But even these, and in fact the whole body, are 
restrained in their development. This weakness is shared to 
some extent by the mental capacity, so that these children are 
crippled in both body and mind. This intellectual infirmity is of 
all grades, from slightly impaired vigor to idiocy. In addition, a 
large percentage of these cases (estimated at about fifty per cent) 
is afflicted with epilepsy, which in most instances is general, but 
occasionally may be Jacksonian. Another comparatively common 
feature of the disease is the occurrence of athetoid or associated 
movements. The former occur as involuntary, slow, and uniform 
movements, usually of the fingers and toes ; the latter as involun- 
tar}' movements by the paralyzed extremity in general imitation 
of voluntary movements made by the healthy extremity. In 
some hemiplegias choreiform movements are seen, and nystagmus 
in some diplegias. In other cases tetanoid movements, rhythmical 
contractions, tremors, and ataxia may at times be observed. Still 



564 THE MEDICAL DISEASES OF CHILDHOOD 

another somewhat rare condition in very young cases is hemianop- 
sia. And in those children who are able to talk aphasia may 
result from a lesion of the motor speech centre. In this connec- 
tion one should mention the occasional occurrence of the post- 
hemiplegic polymyo-clonus of Peterson, a steady clonic contraction 
of some of the affected muscles, which happens at the approximate 
rate of five to a second. 

In most cases the superficial and deep reflexes are exaggerated 
in the affected parts, although a marked rigidity of the muscles 
may render their detection somewhat difficult. It is unusual to 
find them normal or decreased, although this does now and then 
happen. It is no uncommon thing to find one or more of the 
stigmata of degeneration, such as deformities of the skull, face, or 
any of its parts, of the body, genital organs, extremities, and per- 
versions of senses and functions. 

Treatment. — There is no cure for these cases ; and all that one 
can hope to do is to relieve the symptoms, and then to develop to 
the utmost whatever powers of mind and body are left unin- 
jured. The acute symptoms require rest in bed, applications of 
ice to the head, and, in the case of convulsions, the proper doses 
of antipyrine, chloral, bromide of soda, or inhalations of chloroform. 
The general care of the patients should be of the best ; the bowels 
should be kept in a free condition, the food should be nutritious 
and easily digestible, the skin must be made vigorous. Massage, 
passive motion, and electricity, aided by tonics, may help to 
strengthen the weakened muscles. These cases, in order to 
attain a useful position in life, demand special education which 
is designed to develop individual deficiencies. They gain little 
or nothing at the ordinary school, where they are discouraged, 
disheartened, and made to recognize their shortcomings in the 
keenest possible manner. Under skilled direction, which is able 
to locate the mental as well as the physical weaknesses, con- 
siderable improvement may be looked for. Much patience, appli- 
cation, and considerable expense may have to be incurred, but, as 
I have repeatedly seen, the result will commonly justify the 
outlay. Surgery has not as yet been able to give any radical help. 

Prognosis. — The outlook in almost all of these cases is not 
good. Where the lesions are large, as in the paraplegias and 
diplegias, one need not look for recovery. In the other paralyses 
the disability is commonly confined to comparatively few muscles, 



NERVOUS DISEASES 565 

and the steady development of others may atone in part for the 
loss. Thus an arm or a leg may be made somewhat useful, 
defective speech may slowly be improved, and by prolonged 
efforts, rightly directed, the mental condition may be somewhat 
bettered. One should take care to foretell the possible super- 
vention of epilepsy, and especial stress should be laid upon the 
liability of these patients to contract intercurrent diseases, and the 
weak resistance which they are apt to offer to the attacks. 

Differential Diagnosis. — The disease is not hard to recognize, 
and the only disorder that is at all commonly apt to create con- 
fusion is infantile spinal paralysis. In cerebral paralysis, Iioav- 
ever, the existence of the history of the case, the hemiplegia, 
paraplegia, diplegia, or monoplegia, with rigidity and contractures, 
the natural electrical reaction of the muscles, the morbid move- 
ments, epilepsy, and stigmata of degeneration, all are able to fix 
the nature of the disease. 

Thrombosis of the Intracranial Sinuses 

Thrombosis of the intracranial sinuses may result from two 
general causes : one, called primary or cachectic, follows conditions 
of exhaustion, such as those caused by simple atrophy, prolonged 
intestinal disorders ; the other, called secondary or septic, follows 
some form of pyogenic infection. Primary thrombosis, which 
is rather rare in childhood, usually involves the longitudinal 
sinus, and may also extend to the cavernous and lateral sinuses. 
Secondary thrombosis is more apt to be located in the lateral or 
transverse sinuses. The clot may arise either from a coagulation 
in a near-by vein, or directly from an inflammation of the walls 
of the sinus. It finds its origin, in almost all cases, in the 
development of some infective disease that is in active existence 
before the thrombosis begins to be formed. 

The s} T mptoms of primary thrombosis are not easily distin- 
guished, for the patient's condition is so poor, and there are apt to 
be so many serious signs of physical incompetency that in the 
general breakdown the diagnosis is easily overlooked. In the 
secondary form the symptoms resemble in a general way those of 
meningitis, which, by the way, often complicates the process. 
The general symptoms would be prostration, headache, stupor, 
spastic rigidity of the neck or extremities, convulsions, thin and 



566 THE MEDICAL DISEASES OF CHILDHOOD 

irregular pulse, and interference with ocular functions. The tem- 
perature varies according to the circumstances of the complaint. 

Thrombosis of the lateral and petrosal sinuses happens with 
less rarity than the other forms, since it is often secondary to 
some of the aural diseases which are so common in childhood. 
In involvement of the lateral sinus there is oedema over the 
mastoid region, and swelling of the veins. There may or may not 
be some tenderness on palpation, which is confined to the affected 
side. When the superior longitudinal sinus is attacked, which 
commonly occurs in severe anaemia, there is oedema of the scalp 
and swelling of the frontal, occipital, and parietal veins. Throm- 
bosis of the cavernous sinus is often connected with that of the 
petrosal. There are oedema of the eyelids, ptosis, paralysis of 
the external rectus muscle, supraorbital pain, and exophthalmos. 
In some cases there are practically no characteristic symptoms, 
and the diagnosis can be made only on post mortem section. 

The treatment of the secondary form is purely surgical ; and 
the sooner the operation is performed, the better is the chance of 
recovery. Under all circumstances the prognosis is very doubtful, 
not only on account of the severity of the measures, but also 
because the child's condition is regularly so poor. 

Abscess of the Brain 

This rare condition is much less frequently seen in children 
than in adults. The known causes which produce it are never- 
theless comparatively common in these young patients, such as 
otitis media, purulent disease of the nose, infected wounds of the 
scalp and skull, and fractures and caries of the cranial bones, 
cerebral tumors, and metastatic abscesses from any pyogenic dis- 
ease. In some cases the cause cannot be traced. 

Lesions. — The abscess may be encapsulated or non-encapsulated. 
In the former there is an enclosing shell of connective tissue 
which is filled with creamy or greenish pus, broken-down cerebral 
tissue, and bacteria. In the latter the abscess cavity is irregular, 
the walls are necrotic and infiltrated with pus. For a variable dis- 
tance the zone about the abscess is soft, degenerated, and oedema- 
tous. There may be extensions of the process in various directions, 
which thereby involve increasing amounts of tissue. Multiple 
abscesses are usually small, but may increase to a large size by 



NERVOUS DISEASES 567 

coalescence. The usual locations are the temporo-sphenoiclal lobe, 
the cerebellum, the frontal, occipital, and parietal lobes. 

Symptoms. — The abscess may give symptoms immediately, or 
may be latent for weeks or months. Its first manifestations are 
those of pus formation — fever, chills, malaise, prostration, and 
disorders of nutrition. There may be nausea or vomiting, consti- 
pation, and lowered pulse rate. Headache is a constant symptom, 
and may in a general way correspond to the location of the lesions ; 
if the abscess is superficial, there may be a corresponding tender- 
ness of the scalp. Cerebral irritation may be severe, and, especially 
as the pus formation enlarges, may be merged into convulsions, 
which in time may be followed by coma. Optic neuritis com- 
monly ensues, and with it a resulting blindness which may be 
confined to one side. If by extension of the process a meningitis 
begins, it will give its characteristic symptoms. The same may 
be said of involvement of the special localizations of the cerebrum 
and cerebellum ; but these focal manifestations are often not seen 
because the disease is confined to the frontal and temporo-sphenoidal 
lobes. The abscess may in some instances fall into quiescence for 
months or years, and then, for some known or unknown reason, 
undergo an acute exacerbation. 

The treatment is purely surgical ; and the sooner the abscess 
can be opened and drained, the better is the prognosis. Under 
all circumstances the chances of recovery are not great, and when 
the lesions are situated far from the surface the prognosis is abso- 
lutely bad. 

The diagnosis from meningitis may at times be difficult ; but 
if one keeps in mind the tendency to spastic rigidity, convulsions, 
opisthotonos, and superficial location of the meningitis, the diffi- 
culty may be lessened. In addition its course is more rapid, 
uninterrupted, and violent. Commonly there is a history of injury 
or preceding disease, from which an abscess may start, to turn 
our attention to the right opinion of the case. Between abscess 
and tumor a diagnosis may be obtained by noting the apyrexial 
course, the steady growth, and the equally steady increase of focal 
symptoms in the latter condition. An occasional or rare case may 
occur, as an exception to this rule, in which a cerebral abscess 
may give no fever, and in which the symptoms are practically 
identical with those of cerebral tumor. Here the diagnosis can 
be made only on post mortem section. < 



568 THE MEDICAL DISEASES OF CHILDHOOD 

Tumor of the Brain 

New growths of the brain must include those of the cerebral 
tissue proper, its meninges, and those neoplasms of the scalp that 
by wearing a way through the bone finally produce pressure 
symptoms upon the cortex. About fifty per cent of these tumors 
are tubercular, about twelve per cent gliomata, eleven per cent 
are sarcomata, ten per cent are cysts, about three per cent are 
carcinomata, and the remainder is divided among glio-sarcoma, 




Fig. 120. — Neuro-glioma of Brain. X 110. 

angio-sarcoma, myxo-sarcoma, papillary epithelioma, gummatous, 
and unclassified tumors. In such a work as the present, an ex- 
tended description would be out of place. For an exhaustive 
account the reader should consult special works on nervous 
diseases. 

The tubercular tumors are almost always secondary to tuber- 
cular disease in other parts of the body. They may vary in size 
from a pinhead to an egg ; they may be single or multiple, encapsu- 
lated or non-capsulated. Generally the interior of the tumor is 
cheesy, while the periphery is made up of giant cells, granulation 
tissue, and epithelioid cells. 



NERVOUS DISEASES 569 

Gliomata are caused by some mysterious degenerative hyper- 
plasia of the neuroglia. It is generally found in the ependyma 
ventriculorum and the retina. A common characteristic is their 
great vascularity, on account of which haemorrhages may easily 
occur. When the tissue takes on a mucous character the tumor 
is called a myxo-glioma, and a growth of round and spindle cells 
is designated glio-sarcoma. 

Sarcoma has a rapid growth, and therein differs from glioma, 
from which it is also distinguished by the fact that it is sometimes 
multiple. Variations are called myxo, fibro, lympho, glio, cysto, 
melano, angio, endothelial, round-celled, and spindle-celled sarco- 
mata. Its course is malignant. 

Cysts may result from degenerative changes in organic lesions, 
when they are called secondary. Metastatic cysts are caused by 
echinococcus or Cysticercus cellulose. They may be single or 
multiple, and may grow to a great size. 

Symptoms. — There are certain signs that belong to all new 
growths, such as headache, nausea and vomiting, constipation, 
sleeplessness, mental disorders, optic neuritis, dizziness, convul- 
sions, and in some cases enlargement of the skull, erosion of the 
cranial bones, and exophthalmos. In individual cases there may 
be special and characteristic symptoms due to local pressure and 
distension. The growth of the symptoms is slow and gradual, 
and when a sudden outburst of disturbances occurs it is due to 
haemorrhage or meningitis. New growths located in the axis at 
the base of the brain give symmetrical symptoms ; other locations 
produce unilateral signs. 

In the frontal lobe the growths commonly give disturbances and 
decrease of the intellectual faculties, and sometimes their mani- 
festations are slight or latent. There is apt to be an ataxic, stag- 
gering gait, and as the tumors grow they may exert pressure in 
various directions, and thus produce symptoms which do not prop- 
erly belong to their location. 

Those growths which directly or indirectly impinge upon 
the third frontal convolution (in a right-handed person) pro- 
duce motor aphasia, and in older children a partial degree of 
agraphia. 

Growths in the motor area (fissure of Rolando) produce spasm 
(Jacksonian epilepsy), convulsions, or some degree of paralysis of 
the opposite parts of the body, according to their location and size. 



570 THE MEDICAL DISEASES OF CHILDHOOD 

The motor area is supposed to control sensory as well as motor 
functions ; and, therefore, with the disturbances of motor control 
there may be more or less anaesthesia. 

New growths in the parietal lobe show the effects of various 
degrees of anaesthesia in the opposite extremities. It is only by 
pressure which is transmitted to other areas that further localiz- 
ing symptoms arise. 

In the occipital lobe tumors produce homonymous hemian- 
opsia. Here, also, indirect pressure on adjacent areas elicits cor- 
responding symptoms. 

In the temporo-occipital region tumors, which are situated near 
the base of the brain and above the petrous part of the temporal 
bone, produce optical aphasia or visual amnesia by pressing upon 
or destroying the association tract between the occipital and 
temporal region (Starr). New growths of the temporo-sphe- 
noidal lobe may give no symptoms, or indefinite ones, involving 
the senses of hearing, smell, and taste. 

Tumors developing in the lateral ventricles, island of Reil, and 
ganglia at the base, may give rise to a wide variety of symptoms 
because they impinge upon the internal capsule, which acts as a 
station wherein various tracts are received. Thus there may be 
both motor and sensory symptoms, according to the part which is 
affected. 

Tumors in the crura may also produce motor and sensory 
symptoms of one or both sides. Among these are ataxic gait, 
alternate hemiplegia, homonymous hemianopsia, hemianesthesia, 
and optic neuritis. 

Tumors of the corpora quadrigemina give an ataxic gait, pro- 
gressive double ophthalmoplegia, and some degree of paralysis. 
Pressure communicated to the aqueduct of Sylvius produces 
hydrocephalus, and when the crura are similarly involved motor 
and sensory symptoms result. 

Tumors of the pons varolii produce the ataxic gait, and 
disorders of the third, fifth, sixth, seventh, and eighth cervical 
nerves, according to the size and location of the growth and 
transmitted pressure. 

Growths of the medulla oblongata involve a very wide com- 
bination of symptoms on account of the many centres and tracts 
therein contained. Thus there may be disorders of motion and 
feeling, of respiration, and pulse ; there may be vasomotor dis- 



NERVOUS DISEASES 571 

turbances, difficulty in swallowing, projectile vomiting, glycosuria, 
polyuria, impeded sucking and articulation. 

Tumors of the cerebellum give rise to sudden spasm of the 
extremities, which is most commonly shown on arising in the 
morning, the ataxic gait, and vertigo. Communicated pressure 
produces disorders of the pons varolii, cranial nerves, and medulla 
oblongata. Pressure upon the fourth ventricle may cause hydro- 
cephalus. 

Treatment. — The care of these cases is symptomatic, until the 
child is put into the hands of a surgeon for operation. If the 
tumor is deep-seated and the operation is inadvisable, one can do 
nothing but make the child as comfortable as possible. If the 
tumor is syphilitic, which is exceedingly rare, mercury and the 
iodide of potassium will cause an immediate amelioration of 
the condition, most of all if the drugs are prescribed in large 
and increasing doses. 

Prognosis. — Unless the growth is syphilitic, or its situation 
allows removal, the outlook is absolutely bad. A tubercular 
tumor may set up a similar inflammation of the pia mater, and 
may kill the child before the pressure symptoms are very marked. 
Or a haemorrhage may arise from a glioma, and produce the ordi- 
nary picture of a cerebral apoplexy. In a considerable number 
of cases the vitality of the child is so much affected that he dies 
from an intercurrent disease either before or after a diagnosis of 
intracranial tumor can be made. The disease is not supposed to 
last more than two years. 

Differential Diagnosis. — The determination of this condition 
depends upon the recognition of the general symptoms plus the 
evidence of local pressure and destruction. The main items to 
keep in mind are the absence of a sufficient cause (excepting in 
tuberculosis and syphilis), the apyrexia, slow development, head- 
ache, and occasional tenderness of the scalp, and the gradual 
growth of focal symptoms. Mace wen's symptom, " the elicit ation 
of a differential cranial percussion note," should be sought for, 
but not with the expectation of regular success. It is practised 
by means of the finger or percussion hammer while a stethoscope 
is placed on the forehead, or on a shaved patch of the scalp on the top 
of the head. The diseases which may possibly be confused with 
intracranial tumor are tubercular meningitis, abscess of the brain, 
and hydrocephalus. 



572 THE MEDICAL DISEASES OF CHILDHOOD 

Tumors of the Spinal Cord 

The same growths that occur in the brain may also be seen in 
the spinal cord and its meninges. Likewise, outside of tuber- 
culosis, syphilis, and metastasis, there is no known cause for them. 
The number of cases recorded has hardly been large enough 
to found a reliable table of frequency of occurrence. As in cere- 
bral tumor, the reader should consult a special work on nervous 
diseases if he desires an extended account of the disorder. 

The tumor is usually unilateral, but may by extension invade 
the other side. Likewise, the growth may be in the cord itself or 
in the meninges, and from one may extend to the other. In rare 
cases there may be some external evidence of the growth, but in 
the large majority the symptoms are those of pressure grafted 
upon the signs of a degeneration of some section of the cord. 
Extra-medullary growths give pain in the back and the results of 
involving the posterior nerve roots. If the growth is on the 
anterior aspect atrophy and paralysis result. 

In the symptomatology of all sorts of growths, vaso-motor 
disturbances occupy an important place ; the skin is tender and 
painful, flushed and shining. There are muscular wasting and 
paralysis, in degree and locality according to the lesions. If the 
growth is in the cervical region, there will be pain in the arms, 
and especially in some special portions of the brachial plexus ; if 
it is in the dorsal region, the pain is felt in the thorax and abdo- 
men; if it is in the lumbar region, the pain radiates to any part of 
the lumbar and sacral plexuses. The natural progress of the 
disease is a series of increasing symptoms of vaso-motor disturb- 
ances, pain or paresthesia, followed by complete anaesthesia, 
complete paralysis, and finally trophic disturbances. 

The muscles or groups of muscles supplied by the affected 
segment of the cord will, as one can readily understand, become 
paralyzed and atrophied ; but those muscles supplied by the lower 
segments will merely be affected with a spastic paralysis. As 
one would naturally suppose, the only muscles which show the 
reaction of degeneration are those supplied by the affected seg- 
ment of the cord. As the disease of the lumbar region progresses, 
there will be a growing paralysis of the rectal and vesical sphinc- 
ters. When the tumor is in the higher portions of the cord, 
there will be incontinence or retention. In all cases, but markedly 



NERVOUS DISEASES 573 

with tubercular aud syphilitic growths, there is a clispositiou 
toward the development of myelitis, whose progress is apt to be 
rapid. 

The treatment, as in cerebral tumor, is surgical ; but it is not 
often that one may expect a successful result. Before the case 
is operated upon, all one can do is to treat the symptoms. Of 
course this does not apply to syphilitic growths, which improve 
rapidly under the use of mercury and iodide of potassium in large 
and increasing doses. 

The prognosis is the same as in cerebral tumor. To avoid 
confusion, one must keep in mind, as the principal characteristics 
of spinal tumor, the gradual development, apyrexia, unilateral 
involvement, and the gradually increasing localizing symptoms 
which correspond to the position of the neoplasm. There is 
usually no history of a sufficient cause, excepting in the case of 
tuberculosis, syphilis, or a pathological condition which * permits 
metastasis, in which case there would be the evidences of previous 
disease. 

Hydkocephalus 

An accumulation of serous fluid in one or more cavities of the 
cranium is called hydrocephalus, or water on the brain. This 
fluid may be in the subdural spaces, when it is designated external 
hydrocephalus. In other cases the ventricles contain the effusion, 
and this condition is called internal hydrocephalus. An acute form 
is rare, and occurs, as a rule, as one of the symptoms of menin- 
gitis. There is also an acute serous hydrocephalus, described by 
Quincke, whose origin is usually the result of systemic exhaustion, 
although in some cases it is unknown. There are, however, a 
few cases which are due to the venous stasis of marked cardiac 
disease, or new growths at the base of the brain and the posterior 
fossa. The chronic external form is also rare, and follows con- 
genital or acquired atrophy, and congenital malformations of the 
brain, pachymeningitis, and haemorrhage of the meninges. The 
chronic internal variety may be either congenital or acquired ; in 
the latter case it results from neoplasms at the base of the brain 
or chronic meningitis, and is thus a rare manifestation of press- 
ure ; in the former we have the most noteworthy variety, which, 
on account of its greater prevalence and greater importance, is 
usually called, to the exclusion of all forms, by the simple term 



574 THE MEDICAL DISEASES OF CHILDHOOD 

"hydrocephalus." Its causes are unknown, although various sup- 
positions have included tuberculosis, syphilis, heredity, prenatal 
malnutrition, maternal impressions, and alcoholism in the list of 
possibly responsible factors. 

Lesions. — The brain tissue is pale, weak, and does not clearly 
show the distinction between the gray and white matter. The 
fluid is present in various amounts, which, as they increase, produce 
equally great changes in the brain. The convolutions are flat- 
tened and thin, so much so in certain cases that there is nothing 
left but a mere shell ; at both top and sides this may occur. The 
brain at the base is flattened and softened in a less degree. The in- 
creased pressure stretches the sutures and fontanelles out ; the 
bones of the skull are thin, pliable, and bulge at the forehead and 
vertex. The ependyma in mild cases is normal, in severe cases it 
is enlarged, congested, and covered with granulations. In some 
exceptional cases there are variations from the ordinary appear- 
ances ; there may be a premature ossification of the skull with an 
equal amount of compression, although the quantity of fluid is not 
great. In other children there may be a condition of spina bifida, 
or meningocele, or encephalocele in connection with the hydro- 
cephalus. The fluid is alkaline in reaction, of a specific gravity 
of from 1.003 to 1.008, slightly albuminous, and sometimes con- 
tains a trace of sugar. 

Symptoms. — In most cases the head begins to increase in size 
before birth. The fluid first accumulates in the lateral ventri- 
cles ; later, on the aqueduct of Sylvius is stretched out into the 
shape of a funnel, but the fourth ventricle is not much influenced 
except in very marked cases. The fontanelles bulge, and through 
them a wave of pulsation is easily recognized. The shape of the 
head is roughly square, on account of the distension of the ante- 
rior and posterior horns of the lateral ventricles, which causes 
bulging of the frontal and occipital bones. The forehead is 
grotesquely high, and by its marked projection makes a sharp 
prominence at the root of the nose. As the head increases in 
size, the sutures are forced apart and the scalp is stretched tightly 
over the skull. The weight of the head may be so great that the 
child cannot support it without aid. If he lives long enough he 
may be able to acquire sufficient strength so that he can sit up ; 
but, in spite of this gain, the head is still too heavy for him, and 
topples over to one side or the other. The eyes project outward 



NERVOUS DISEASES 575 

and downward, and are only partially covered by their lids. 
Muscular growth is retarded, and in the lower extremities some 
degree of rigidity may be remarked. The thumbs are often held 
within the closed fist, the eyes may have a convergent squint, and 
convulsions may at any time ensue. The mental development 
is much retarded, both in the direction of sense perceptions and 
intellectual effort, so that the child remains in some degree of 
imbecility. 

Treatment. — Treatment by means of drugs gives no good re- 
sults, excepting in some cases of syphilitic heredity, which im- 
prove under the use of mercury and the iodide of potassium. 
Surgical means have been tried in great variety, and likewise 
without success. This also has been the experience with strap- 
ping, aspiration, lumbar puncture, counter-irritation, craniotomy; 
and none has given such satisfactory results that it may be recom- 
mended as a remedy of wide application. On the other hand, 
since these cases are generally forlorn hopes, any method which 
appeals to the individual operator and is justified on good surgical 
principles may be tried. At the same time, one should plainly 
understand that the outlook is not good. Some cases, especially 
the congenital, die within a few months ; from these rapid involve- 
ments nothing in the way of cure or improvement need be ex- 
pected, even long before the fatal stage of the disease. There 
are, however, instances of very slow growth which generally are 
secondary; these by the use of tonics may be restrained from a 
full development of the disease, and eventually may enjoy a fair 
degree of health and mental ability. Cases of extreme enlarge- 
ment followed by rupture of the head have been reported. 

Differential Diagnosis. — Those few cases of premature ossifica- 
tion in which hydrocephalus is concealed cannot be certainly 
diagnosticated. With the other cases the diagnosis is largely a 
matter of discerning the increased size of the head. It is true 
that increase in the cranial measurements may occur in rickets 
and syphilis ; but differentiation from two such diseases with their 
strongly marked symptomatology is rarely difficult in an appreci- 
able degree. 

Asthma 

Asthma is a neurosis, one of whose main symptoms is a certain 
prolonged form of respiratory spasm. As a rule, the term is 



576 THE MEDICAL DISEASES OF CHILDHOOD 

frequently misunderstood and misapplied. Physicians as well 
as laymen commonly think of it as applicable to almost any form 
of dyspnoea without much regard to the exciting cause. 

Causes. — In some cases of asthma, one can find antecedent 
examples of the disease in parents or ancestors. Nevertheless 
one can scarcely say that the disease is a matter of strict heredity. 
Rather one should regard the appearance of the symptoms as the 
evidence of a predisposition to a certain nervous irritability which 
in the presence of proper physical conditions and an exciting 
cause may develop in ways that are analogous to those of heredity. 
The transmission of this neurosis has not the sureness, the steady, 
inevitable character, of an hereditary trait. 

As auxiliary active causes, many disorders of the respiratory 
track and its connections take a front rank. Doubtless the prin- 
cipal of these are enlargement of the bronchial and tracheo- 
bronchial glands, and bronchitis. It is commonly supposed that 
these causes act by irritating and pressing upon the vagus or its 
ramifications. In addition to disorders of the bronchi and bron- 
chial glands, any abnormal condition of the larynx, throat, or nose 
may induce an attack of spasm. Hyperesthesia of the mucous 
membrane covering the turbinated bones of the nose, or deviations 
and growths of the septum, are likewise efficient in creating the 
symptoms. Occasionally the disorder seems to arise from or to 
have an intimate connection with renal, cardiac, or thymic disease ; 
but it is practically impossible to make a minute classification of 
the relationship. 

Besides all this, there are many causes which act in a more 
remote way : a strong, harsh wind, certain odors, the pollen of 
plants, dust, even such obscure changes as those involved in sexual 
disease, skin diseases, intestinal disorders, — in short, almost any 
pathological state can, by nervous irritation, precipitate an attack. 
In some cases a purely psychical reaction may, in some mysterious 
fashion, have an immediate and active effect. Thus, in some rare 
cases a stream of light may suddenly change the normal breathing 
to violent respiratory efforts, or, on the other hand, the approach of 
darkness may have the same effect. In a noteworthy case of a boy 
of fourteen, whom I observed for upward of three years, the touch 
of plush, velvet, or the velvety skin of a ripe peach, acted with 
characteristic promptness. Finally, one may mention the uric acid 
diathesis and enlargements of the thyreoid gland as possible causes. 



NERVOUS DISEASES 577 

Lesions. — The changes in the nervous system, whatever they 
may be, are as yet impossible to define. That there is in some 
cases a hypersesthetic condition of the nerve filaments in the nasal 
mucous membrane is beyond dispute ; it is entirely within reason 
to expect that eventually we may know as surely of a nervous 
irritation which more or less directly produces the symptoms of 
the disorder. There have been many theories concerning the 
probable development of the lesions, all the way from the first 
utterances of Van Helmont, through the theory of bronchial spasm 
of Biermer, the theory of tonic spasm of the diaphragm put forth 
by Wintrich and Bamberger, to the Weber-Stoerk theory of vaso- 
motor disturbances in the circulation. At all events, when the 
neurosis is once in active existence, we know that a bronchitis, 
an emphysema, and sometimes inflammatory changes in nose, 
pharynx, and throat develop. In such an event the ordinary 
pathological changes which belong to these diseases will naturally 
show themselves. On careful examination one is very apt to find 
a more or less extensive adenitis, or abnormalities in the inner con- 
formation of the nose, or nasal polypi. After a prolonged series 
of attacks one is apt to find a marked absence of elasticity in the 
lung tissue, a chronic bronchitis, a dilated heart, and possibly an 
endocarditis with insufficiency. 

Certain changes have been noticed, the exact significance of 
which is not understood. For instance, Von Noorclen and Muller 
claim that the blood of asthmatic patients contains an increased 
number of eosinophile cells. Another noteworthy fact is Leyden's 
discovery of the elongated crystals, which Charcot noted in other 
diseases, associated with mucous shreds. Most renowned of all 
is Curschmann's isolation of the so-called spirals ; these consist 
of threads of mucin wound in strands about a central axis, some- 
times much twisted, sometimes puffed out with air so as to assume 
a fusiform shape. These spirals are dotted here and there with 
small round cells, spindle-shaped cells, and epithelium. Cursch- 
mann's spirals have been seen in the expectoration of various 
pulmonary diseases. 

Symptoms. — Commonly the symptoms appear at night, fre- 
quently without warning. The child may wake from a quiet 
sleep with the signs of anxiety and fear. He feels as if he could 
not breathe, and straightway tries by all the aids of position and 
extreme respiratory effort to obtain more air. As the attack 

2p 



578 THE MEDICAL DISEASES OF CHILDHOOD 

increases in severity, inspiration becomes spasmodic while expira- 
tion is prolonged, labored, and wheezing. More and more the 
child puts forth every effort to satisfy his air hunger, and every 
effort seems futile. On account of his failure he becomes more or 
less cyanotic, his extremities are cold, his face is clammy with a 
slight perspiration. The suffering is pitiful, and may continue 
for minutes or hours. As the attack lessens, the symptoms are 
apt to be replaced by those of bronchitis with the ordinary cough, 
its physical signs, and a thick, viscid expectoration. 

A noteworthy fact is that the respiration, although so strenu- 
ous, is not increased in rapidity ; on the contrary, in very severe 
attacks the rate may be lessened. With each short, spasmodic, 
and strong inspiration the upper part of the chest seems to rise 
in a convulsive movement, but the lower part appears scarcely at 
all to move. Expiration is as forceful as the physical powers of 
the patient allow. Percussion and auscultation will give the 
symptoms of acute emphysema, but after the attack has subsided 
the physical signs of acute bronchitis are apt to be superadded. 
The pulse is weaker, thinner, and somewhat more rapid than in 
health. 

Treatment. — If the asthma is due to an antecedent pathologi- 
cal condition, such as abnormalities in the nose, or throat, or 
glands, then patient efforts must be directed to their cure. For 
the relief of the asthmatic attacks, one obtains most satisfaction 
from chloral hydrate or antipyrin, the latter given with a cardiac 
stimulant. During the day small doses of potassium iodide, gradu- 
ally increased, will give benefit. Many drugs, such as stramonium, 
lobelia, amyl nitrite, opium, quebracho, and grindelia robusta, have 
been recommended and used. But on the whole, one is apt to 
obtain no more than an intermittent satisfaction from them. The 
main thing to keep in mind is that the neurosis has no specific 
cure, that the means first suggested will in almost every case be 
sufficient to alleviate the distressing symptoms, and that when the 
attack is fairly ended, every possible method of improving the 
general health must be used. The attendant has here the oppor- 
tunity of displaying resourcefulness in the administration of 
tonics, wisely ordered sanitary arrangements, exercise, and climatic 
changes. 

Prognosis. — The outlook, especially in young cases, is good. 
Nevertheless, there is danger of a dilated heart, an emphysema, 



NERVOUS DISEASES 579 

a chronic bronchitis, or a bronchiectasis which may remain as 
a sequel. 

Hay Fever 

Hay fever, also called rose cold, and autumnal catarrh, is a 
neurosis that is closely allied to asthma. Indeed it has been 
called "a nasal form of asthma." The two disorders are so 
closely allied as at times to be indistinguishable. 

Causes. — The main foundation of the disease seems to be an 
hereditary susceptibility that, under the impulse of sufficiently 
active irritants, suddenly starts the symptoms into activity. 
Locally the hyperesthesia is situated in the mucous membrane 
of the nose. Upon this sensitive area various irritants have the 
most marked effect. For the most part these irritants are the dust 
and pollen of the goldenrod (Solidago odorata) and ragweed 
(Ambrosia artemisicefolict) in America, Antlioxantum odoratum 
in England, the rye blossom in Germany. There are isolated 
cases in which the pollen of various other grains and grasses 
have a similar effect. That there is, as in asthma, an undoubt- 
edly neurotic element in the causation, is proved by the number 
of cases which have their ostensible starting-point in an hysterical 
impression. In addition, one should mention those cases of ab- 
normality in the nose, such as deviations and growths of the 
septum, and disorders of the mucous membrane. Among the 
many individual and indefinite causes are sense-impression, 
the lithsemic disposition, and some drugs. 

Lesions. — In this disorder the mucous membrane of the nose, 
eyes, and throat become acutely inflamed, showing the usual 
products of catarrhal inflammation. This process in typical 
cases is most apt to spread to the trachea and bronchi, and even 
to the finer bronchial ramifications. In a well-marked case the 
lesions finally become coincident with those of asthma. 

Symptoms. — The common division of the symptoms into the 
so-called catarrhal and asthmatic types is not necessarily a logical 
one. By insisting upon it one opens the door to confusion between 
the real hay fever and an acute rhinitis. The disorder as a rule 
is prevalent in this country from the middle of August to the 
beginning of November, in England in June and July. It be- 
gins with gradually prolonged and violent sneezing, and a painfully 
acute tickling of the nose. The mucous membrane of the eyes, 



580 THE MEDICAL DISEASES OF CHILDHOOD 

nose, and throat becomes inflamed, and secretes a characteristic 
discharge. There are apt to be pains in the face and head, and 
some general prostration. 

The temperature, pulse, and respiration are not materially 
affected. Later on the bronchial structures may be involved, 
with possibly the final occurrence of an acute emphysema. The 
logical development of the disorder results in a variable degree 
of asthma, which is apt, with successive attacks, to increase in 
severity. And this element in a sharply differentiated case of 
hay fever should be present, possibly in very slight degree in 
the beginning of the disorder, progressively more and more with 
recurring attacks. In addition, the demonstration of some hyper- 
sensitive point in the nasal mucous membrane will make the diag- 
nosis more clearly defined. Unless influenced by treatment, the 
disease lasts from one to two months. 

Treatment. — The treatment must be directed to the control 
of the factors of the hypersensitive area and the active cause. 
The offensive pollen must be kept from the nose by one of the 
various methods of filtering the air ; the best and most radical 
means, however, is a change of locality and climate. Any struc- 
tural abnormalities in the nose should be corrected, and the hyper- 
sensitive portion of the mucous membrane may be cauterized. 
For the immediate relief of the symptoms, a weak solution of 
cocaine may be used in the nose, and a saturated solution of 
boric acid in the eyes. The usual plan of treatment in asthma 
will be needed. Before an expected attack, every means should 
be used to promote the local and general health. 

Prognosis. — The prognosis in children who are treated wisely 
and patiently is on the whole good. This is especially true if 
after the first attack the right precautions are observed before 
the next one is due. 

Sporadic Cretinism 

When Hilton Fagge described this condition in 1871, no 
cases were known to have occurred outside of the localities where 
it is endemic. Since then the number of cases that are recog- 
nized is constantly increasing. And now in almost any large 
clinic for children instances of myxoedematous athyreosis are 
usually seen every year. The cause of the disease is the action 



NERVOUS DISEASES 581 

of some agent which, before or after birth, so affects the thyreoid 
gland as to induce myxedematous degeneration and atrophy. 
Like results have followed the experimental removal of the gland 
in human beings and monkeys. The disease may occur in one or 
more children in a family where the parents are healthy. In 
some cases the parents were related, in others there was a history 
of precedent acute disease, but we are ignorant of the value of 
these facts as ^etiological agents. 

Symptoms. — These cases may occur congenitally, or may 
develop in the first year or two of life. Doubtless a larger num- 
ber than was formerly believed is congenital, but on account of 
deficient observation has not been recognized. The disease 
is easily recognized by the dwarfed figure, the lack of develop- 
ment, and a peculiar brutish expression of face. The head is 
large, heavy, brachy cephalic ; the hair is dry, hard, and often 
coarse. The forehead is low and broad, the nose is flat, and about 
the eyes there is an cedematous, puffy condition of the tissues. 
The skin is dry, thick, somewhat wrinkled, and has a greenish 
yellow hue that suggests a combination of anaemia and jaundice. 
The teeth are slow in appearing, the lower jaw is prognathous. 
The tongue is macroglossic, protrudes from the mouth, and the 
poor development of the cheek muscles permits the saliva to 
dribble and drain from the heavily flaccid lips. The voice is 
harsh, thick, and on inspiration there is often a crowing sound. 
The neck is short and thick, the hands flat and saucerlike, the 
abdomen is thick and heavy, the genitals may be large or unde- 
veloped, and the legs undersized. The internal temperature is 
commonly subnormal, anaemia may be marked, haemoglobin is 
reduced, and in some cases there is a considerable degree of leuco- 
cytosis. These children grow very slowly in body and mind, 
so that at the age of eight or ten they may present the appearance 
of being no more than two or three years of age. They make the 
impression of being idiots, in many cases they are unable to talk, 
or to rise much beyond the condition of brutes. They are liable 
to have fatty tumors, the seat of which is commonly confined to 
the upper part of the torso. 

Treatment. — Remarkable progress is made by the use of 
thyreoid extract, the dose of which is 0.03 gramme (gr. J) given 
two and then three times a day, for a child under eight months of 
age. The dose will have to be increased as the child grows older. 



582 THE MEDICAL DISEASES OF CHILDHOOD 

When the remedy is stopped, the patient shows a strong tendency 
to relapse into his original condition ; the younger the child, the 
better may one expect the results to be, and the less difficulty is 
there in maintaining them at a good level. Nevertheless, it is 
doubtful whether these children, even under good circumstances, 
are able to attain more than a very ordinary grade of development. 

Amaurotic Family Idiocy 

This condition has been described as " a fatal disease of infancy 
with paresis or paralysis, accompanied by idiocy or imbecility and 
progressive blindness ; with symmetrical changes in the macula 
lutea." The first traces of it were accidentally observed by 
Warren Tay in 1881. Since then we have been made familiar 
with the symptomatology by a number of writers, foremost among 
whom is B. Sachs of New York. 

The cause is unknown, but the disease occurs in families. 
Almost all the cases occurred in the children of Eastern or Russian 
Jews who are well known to be peculiarly subject to neurotic 
degeneration. 

Lesions. — The changes seem to represent, according to the 
opinion of Sachs and others, an arrest of development. The pia 
mater and arachnoid are thickened, the cortex of the brain is 
hardened, and the strata of pyramidal cells in the cortex are in- 
distinct. The large and small pyramidal cells are somewhat 
rounded, the protoplasm is irregularly shrunken about the nu- 
cleus, and has lost its granular character. The upper portions of 
the cord are in a condition of ascending degeneration. In some 
cases there is atrophy of the optic disks. 

Symptoms. — The children at birth seem normal, and may so 
continue for three, four, or five months. Then, instead of develop- 
ing still further, their growth remains as it was, and in addition 
the child begins to lose vitality and activity. They become 
passive and stupid, their muscular strength fails progressively, 
so that, instead of trying to grasp objects, crawl about, or sit up, 
they remain flaccid and quiet. The head is not raised, the limbs 
are motionless, and the appearance of paralysis with or without 
spastic contractions may be counterfeited. As a rule the. reflexes 
are increased, but in some cases may be absent. Joined to the 
relaxation and flabbiness of the muscular tissue there is a corre- 



NERVOUS DISEASES 583 

sponding weakness of the mind. The child is without curiosity 
and lacks expression, and, unless irritated, takes no notice 
of what is going on about him. Gradually he becomes blind, the 
pupils contract and dilate without much cause, and there may be 
hyperacuity to near-by sound. Ophthalmological examination 
shows in the locality of the macula lutea a fairly large, rounded, 
white spot in the centre of which is a cherry-red or brownish red 
patch. The disks are of yellow-gray color, and present the appear- 
ance of atrophy. In two cases that I saw there was oscillatory 
nystagmus. The abdomen is large, the bowels constipated, and 
as the disease advances the child declines into a condition of mal- 
nutrition or marasmus from which, or from some intercurrent 
disease, he dies. 

The disease may continue until the child is from one to six 
years of age. So far as we noAv know it is always fatal. The 
treatment is symptomatic. Even the requirements of the passing 
phases of the disease are at times difficult to meet ; and the care 
of the case is uniformly unsatisfactory. 

Idiocy 

There are no hard and fast lines that divide the various 
degrees of defective mentality. The full degree of deficiency we 
call idiocy, the lesser degrees, imbecility, and a weakening of 
normal powers, feeble-mindedness. The distinction between them 
is an arbitrary one, and each observer may call any one condition 
by the name that seems good to him. Just as it is impossible to 
draw a line between idiocy and imbecility, so one is unable to 
mark off the dividing line between imbecility and weak-minded- 
ness. Between all these states there are innumerable gradations, 
and these steps lead so insensibly up to the wide threshold of 
health that one can never be quite sure of one's position. More- 
over, the normal mental condition of childhood is not the normal 
mental condition of adult life, and the lack of equilibrium in the 
former partakes very much of the nature of weak-mindedness. 
Finally, we are thrown back upon the idea of infinite variation 
from an ideal norm, the exact dimensions of which no one has 
defined. 

The causes have been generally stated to include almost every 
abnormal condition that can possibly affect children in their con- 



584 THE MEDICAL DISEASES OF CHILDHOOD 

ception, intra-uterine development, and extra-uterine life. In 
many cases claims of aetiology have been made upon insufficient 
grounds, the assumption being made that abnormal growth must 
result from abnormal conditions. At the same time there has 
always been a disposition to overlook the normal results that 
may succeed these same conditions. Thus, consanguineous mar- 
riages have been supposed to be a fruitful source of mental 
defects, and instances of this tendency are commonly related by 
laymen and medical men ; on the other hand, if a careful sum- 
mary of all such marriages were made, one would, I am sure, be 
surprised at the really small percentage of feeble-minded children 
that resulted from them. Injuries to the mother during preg- 
nancy is another common causal factor ; nevertheless, the large 
majority of women who bear normal children have at some period 
of gestation sustained injuries of more or less seriousness. If the 
child proves to be deficient, a search is made for some possible 
trauma that will serve as a hook upon which to hang the garment 
of responsibility. But the same injury, or greater ones, are passed 
over without a thought so long as the child appears to be fairly 
normal. The same idea may be applied to the various sicknesses 
which may fall upon the pregnant woman or upon the child in 
the first weeks, months, or years of life. The only places where 
we feel perfectly at ease are in the cases of epileptic and insane 
descent, and mixtures of them, of hereditary syphilis, cretinism, 
and actual, palpable injury to the skull and brain. For the rest, 
the balance seems to lie in a more or less fortuitous arrangement 
of the elements of nutrition, which may or may not be disarranged 
under various pathological conditions. And when more is defi- 
nitely known about the elements of nutrition, a step will be taken 
in the direction of preventing or modifying the results of their 
unfavorable development. 

It may be worth while to give one of the most satisfactory 
classifications that have been made ; at the same time the reader 
must recognize the purely provisional character of this arrange- 
ment, and that it is given, not because it is fully competent to 
cover and explain the cases as we see them, but merely because as 
yet there is nothing better. The classification is Shuttleworth's. 

Class A. Congenital. 

1. Microcephalic. 

2. Hydrocephalic (also non-congenital). 



NERVOUS DISEASES 585 

3. Scrofulous (Mongol type). 

4. Sensorial (also non-congenital). 

5. Primarily neurotic. 

6. Paralytic (also non-congenital). 

7. Choreic (also non-congenital). 

8. Cretinoid. 

(a) Sporadic. 

(b) Endemic. 
Class B. Non-Congenital. 

9. Eclamptic. 
(a) Developmental. 

10. Epileptic. 

11. Syphilitic. 

12. Post-febrile (also accidental). 
(6) Accidental or Acquired. 

13. Toxic. 

14. Traumatic. 

15. Emotional. 

16. From Mixed Causes. 

The pathology includes any and every form of cerebral 
deformity, injury, and degeneration, and none can be selected 
as typical. Likewise it is plainly impossible to go into the symp- 
tomatology, which may include all variations from normal action 
of nerve structures. 

This subject, which has never been adequately treated, needs 
prolonged investigation and extended exposition. 

Insanity in Childhood 

Insanity, while rare, is not unknown in childhood. Cases of 
mania have been reported in children of two and three years of 
age. And as the children grow older the liability becomes 
greater. It is at the time of puberty that the tendency to un- 
soundness of mind becomes most pronounced. 

Causes. — The main cause lies in heredity, too close inbreed 
ing in tainted families, the crossing of epileptic and insane 
stocks ; brain disease and cerebral injuries may be followed by 
it. And the acute disease, masturbation, worry and mental 
strain, and pathological organic and functional conditions of 
almost all sorts may in the presence of a predisposition act as 



586 THE MEDICAL DISEASES OF CHILDHOOD 

the starting-point. The principal factors are heredity, predis- 
position, and injury. 

Forms of Insanity. — Imperative concepts quite commonly 
appear in childhood and may be of the widest variety, ranging 
from physical acts to pseudo-philosophical questions. 

Mania is not rare as a post-febrile condition, but as a per- 
manent state it is not often seen. There is in it an absolute 
lack of restraint; there are wild flights of fancy, indecency of 
action and speech, and violent demonstrations of all sorts. It 
may and often does follow a period of depression. 

Melancholia carries with it reasonless and marked depression. 
The child wishes to be alone, cannot be amused or interested, 
and finds in his acts or surroundings some cause for brooding 
and humiliation. He may even try to injure himself or commit 
suicide, and herein he differs from the maniac who turns his 
violence against others. The melancholy child sees visions, 
hallucinations, and while he sees them his depression is worst. 
This disorder is probably the one most frequently seen. 

Epileptic insanity is by some observers considered common, 
Wildermuth believing that eighty per cent of infantile epileptics 
are of unsound mind. While these children, as a rule, show a 
tendency to epileptic attacks alone, nevertheless they at times 
change them for seizures of idiocy and dementia. 

Moral insanity may occur at almost any except the very ear- 
liest age, and with it is commonly associated some intellectual 
defect, or at any rate some of the stigmata of degeneration. It 
may occur in children who have not had moral training. The 
evil tendency may take almost any vicious direction, — klepto- 
mania, pyromania, homicide, perverted sexuality, noteworthy 
lying. 

Neurasthenia, hypochondriasis, periodic insanity, cataleptic in- 
sanity, paranoia, acute dementia, and divers psychoses are also seen. 

The treatment of these cases is very much like that of the 
adult forms. If any change is indicated, it is in the direction 
of more individual attention and an exaggeration of the element 
of environment. Since this subject really belongs to special 
works, it is not possible to go into all details of how to care for 
the particular cases. While the prognosis is somewhat better 
than in adults, nevertheless the patient must, for years after 
recovery, be regarded as potentially unreliable. 



NERVOUS DISEASES 587 

Functional Aphasia 

As the result of some mental impression, such as fright, or in 
chorea, or after the acute infectious diseases when impoverishment 
of the nervous system is both possible and probable, a child may 
temporarily lose the power of speech. The condition, so long as 
there is no sufficient organic lesion at the bottom of it, is not a 
serious one, and will gradually improve as the patient becomes 
stronger. 

Deficiency of Speech from Peripheral Paralysis 

After diphtheria and other infectious diseases there may be 
some degree of pharyngeal or palatal paralysis. There may be a 
proportionate inability to enunciate clearly and well. In most 
cases there is a gradual improvement, especially if the child is 
patiently trained. Not every case is quite successful, but one 
should have a sufficiently sanguine view to encourage unremit- 
ting efforts at developing whatever power exists. 

Lisping 

Lisping is a defect of speech in which the person substitutes a 
certain soft sound for a certain hard one, as z for s or d for t. 
The deficiency is commonly interpreted as a necessity for pronounc- 
ing s as if it were th ; but as a matter of fact this is only one form 
of lisping. It may be caused by faulty position or faulty develop- 
ment of some of the speech organs, in other cases it is due to habit 
or imitation. It is often cured by patient and careful teaching. 

Stuttering 

In early years the stuttering habit is easily acquired. It con- 
sists in an inability to connect the different sounds in a word, 
although each sound is perfectly produced. Sometimes children 
who are perfectly normal may acquire it as the result of imitation. 
In other cases it starts from confusion, self-consciousness, or 
fright that is often repeated. More commonly it comes in de- 
bilitated, choreic, and nervous conditions, and may be a sign of 
degeneration. Most children recover spontaneously ; in prac- 
tically all cases a cure can be obtained by careful instruction and 
effort. 



588 THE MEDICAL DISEASES OF CHILDHOOD 

Stammering 

This word is used to designate a speech-defect in which the 
child is unable properly to pronounce individual sounds. It may 
be due to habit, imitation, or faulty development or condition of 
some of the organs of speech. Children whose physical condition 
is poor are more liable to suffer from it than those who are robust. 
The cure lies in careful training and the betterment of the im- 
perfect physical conditions. 

Backwardness in acquiring Speech 

This may be the result of slow but sufficient development, or 
of insufficient development due to sickness. The usual limit 
of acquiring a fair amount of speech is two years. If after that 
time a child, who is not deaf, cannot articulate, he may be regarded 
as mentally deficient. 

This condition finds its extreme in alalia or a total lack of 
speech-function. It is normally present in young infants, but in 
older children it signifies some degree of weak-mindedness, imbe- 
cility, or idiocy. 

ECHOLALIA 

Echolalia is the term applied to an hysterical condition in 
which the child is forced by some nervous impulse to repeat in a 
violent tone the last word of a spoken sentence or phrase. It is 
associated with other hysterical manifestations, and it is apt to 
pass away as the patient's general condition improves. 

Coprolalia 

Coprolalia is another hysterical disorder in which the child is 
impelled to shout some profane, obscene, or foolish expression, 
with the accompaniment of a violent contortion or absurd twitch- 
ing of a part or the whole of the body. It does not occur alone, 
but rather is merely a symptom of a general poor condition. It 
improves under general treatment. 

Disorders of Sleep 

A normal infant is an eating and sleeping animal ; and of 
these two functions sleep is not the less important. For the first 



NERVOUS DISEASES 589 

month or two he should sleep all the time that is not consumed 
in nursing, and being bathed and dressed. The waking time 
gradually increases until it measures about eight hours at one- 
half year, and about ten hours at one year of age. This amount, 
usually divided into two parts in the first few years of life, grad- 
ually increases until at puberty a healthy child obtains about ten 
hours of undisturbed rest. 

The cause of disturbed sleep in early childhood, outside of 
real sickness, is some disorder of the natural functions. In most 
cases this is an interference with normal digestion. Either the 
patient is fed too little or too much. A very common fault is 
the unduly short intervals between the feedings. In this way 
the stomach is unable to complete a given task before a new piece 
of work is imposed upon it. Exhaustion must necessarily result, 
and with it an inability to digest food, so that the child may 
practically be underfed, although the supply of food is excessive. 
Or the quality of food may be poor, so that a relative starvation 
ensues whether or not the actual quantity taken into the stomach 
is much or little. The cases of deficient quantity as well as qual- 
ity are. so rare and so evident as to need no mention. Usually 
the acute disorders are gastric or gastroenteric, while the sub- 
acute are enteric. In other cases the cause may be defective 
ventilation, lack of quiet, the irritation of teething, lack of 
cleanliness, and the errors due to poorly arranged environment. 
In nervous or sensitive children, the reason may lie in domestic 
tumults, in exciting scenes and incidents, in the straining ambi- 
tions so commonly seen in competitive tests in school or home life, 
or in the keen anticipations of desired events. When such a con- 
dition becomes exaggerated, a careful search should be made not 
only for some functional cause, but also for some physical or en- 
vironmental condition which may, although not suspected by the 
mother, be at the root of the trouble. Thus hypertrophy of the 
pharyngeal tonsil, a long or tight prepuce, or other condition 
which induces nocturnal enuresis, may be found ; and often the 
rectification of the fault will remove the evil effects. When the 
disordered sleep occurs in children who are well past the age of 
infancy, it commonly takes the form of nightmares or night ter- 
rors, both of which come under the heading of pavor nocturnus. 
The first designates a condition brought on by non-nervous 
causes, such as overfeeding or indigestion, in which the child 



590 THE MEDICAL DISEASES OF CHILDHOOD 

wakes up after or in the midst of a terrifying dream, and by it is 
thoroughly frightened. The second denotes nervous conditions 
in which hallucinations exist in sleep. The child may wake in 
terror with or without full recognition of circumstances and the 
people about him. No recollection remains the next day of what 
happened. This condition is often associated with known nerv- 
ous disorders, such as hysteria or chorea or epilepsy. 

The treatment in all these cases is as far as possible to remove 
every cause of irritation, to regulate all details of the child's life, 
and especially to arrange the diet and the possible causes of great 
excitement upon a fairly wise plan. When there are physical 
disabilities, such as adenoid vegetations or adherent prepuce, they 
should be removed. With corrective treatment the use of seda- 
tives, such as the bromide of soda, may be combined. If the 
cause of the disorder is promptly diagnosticated, relief is almost 
sure to come. 

Adventitious Sucking 

The young infant in his waking moments obtains his only 
pleasure in nursing. The instinct of self-preservation leads him 
to suck on whatever comes or is put into his mouth. Since grati- 
fication of this desire is the most important thing that he desires, 
it will temporarily at least distract his attention from other im- 
pressions, even if they are moderately unpleasant. Restlessness 
from any cause is so regularly quieted, at all events for a short 
time, by sucking at the breast or the nipple that one can easily 
understand how a perversion comes to exist, and the mere symbol 
of taking food replaces the act. Mothers and nurses frequently 
take advantage of this, and in order to keep the child still, give 
him a rubber nipple, a " sugar-teat," a piece of ivory, or other 
foreign substance with which he may busy himself. Gradually 
the child becomes used to his "comforter," as I have heard it 
called, and insists upon having it whenever he is not nursing. 

Sometimes children find out about the " comforter " without 
another's aid, and then use whatever object is within reach. It 
may be a thumb, a ringer, the toes, the bed-clothes — in fact, any 
object upon which the attention has been fixed. In a few cases 
the practice may be accompanied by rubbing or scratching some 
part of the body. Under all circumstances the habit should be 
stopped at its inception. Mothers should understand that if a 



NERVOUS DISEASES 591 

child is in perfect health, he needs no such aid to keep him quiet ; 
and that if a comforter becomes necessary, not as the result of 
habit, but before the habit is formed, there must exist some cause 
of irritation which should promptly be removed. Among the 
penalties which may follow this habit are disorders of digestion, 
septic infection of the gastric contents, deformities of the thumb, 
finger, or toes, as well as lips, teeth, and jaws. Occasionally a 
tendency toward masturbation may result. 

The treatment usually requires no more than a fair amount of 
intelligence and patience. The child must be restrained from the 
indulgence. No artificial " comforter " should be allowed, and if 
he selects the thumb or any other similar part, it should be so 
swathed as to prevent the act. The child may be cross and 
irritable for a few days ; but if the treatment is regularly carried 
out, he will soon become resigned and forget his former longing. 
There are no circumstances which excuse or justify the habit. 

Masturbation 

This habit may be contracted and followed at any time of life, 
from the first few months of life. In infants the tendency to it 
may be spontaneous, or may be developed by a vicious nurse, 
who seeks thereby to keep her charge quiet. Every observer who 
treats large numbers of children, finds instances of this habit at 
all ages, in all classes, and in various forms. Sometimes the 
hand is used as the active agent, sometimes friction against furni- 
ture or bedding, sometimes thigh-friction, and I have seen in a 
baby girl the producing of the act by means of the heel. In 
spontaneous cases occurring in infancy, the tendency is usually 
a mark of sexual perversion or degeneracy. In older children it 
may be acquired by imitation, teaching, or accident. Local causes, 
such as a long, tight, or adherent prepuce, phimosis, adherent 
clitoris, or an inflammation of the skin in the neighborhood, may 
be the starting-point ; in other cases the habit may be traced to 
intestinal parasites, especially thread-worms, to irritating urine, 
to certain exercises and amusements, such as tree-climbing. 

In many children no especially bad results may be noticed in 
early years. In others there may be nervousness, irritability, 
lack of confidence, bashfulness, lack of energy and vitality ; 
occasionally some serious nervous disorder, such as hysteria, 
epilepsy, or even insanity, has seemingly resulted from the habit. 



592 THE MEDICAL DISEASES OF CHILDHOOD 

The treatment consists in some form of restraint in combina- 
tion with the removal of abnormal physical conditions. Thns, a 
long, tight, or adherent foreskin may be amputated ; a phimosis 
may be reduced ; an adherent clitoris may be freed ; intestinal 
parasites should be removed ; and disorders of the skin may be 
cured. Sometimes one's ingenuity will be severely taxed to find 
means which are sufficient against the low cunning of the occa- 
sional child. One must make a resolution that the habit is to 
be followed up and stamped out, even if much time and effort are 
thereby consumed. If there are local causes at work, they must 
be removed. 

Deaf-Mutism 

Deaf-mutism may be congenital or acquired. In the former 
it may or may not be associated with some degree of idiocy. 
When the mental condition is good, it may be caused by colloid 
degeneration of the labyrinth, absence or disease of the semi- 
circular canal or related parts of the ear, diseases of the brain, 
imperfect development of the petrous bone, and diseases of the 
skull. In the acquired form it may follow the acute infectious 
diseases, especially those which are associated with purulent 
diseases of the ear ; diseases of the brain and meninges, and 
atrophy of the auditory nerve, may bring about a like result. In 
general, one may say that conditions which destroy the hearing of 
children who are under five or six years of age will occasion deaf- 
mutism. Not all cases show the defect in equal degree ; cranial 
conduction gives a means of hearing in a large proportion of the 
cases, while not a few preserve some part of the natural faculty. 

In children who are not idiotic much may be done by proper 
methods of instruction to atone for the loss of hearing and speech. 
Normal children attain the ability to speak when they are two 
years old ; if this time passes without the development of speech, 
artificial training should without much delay be instituted. 

Convulsions 

Convulsions, or eclampsia neonatorum, is a symptom that has 
many causes, and occurs with the most widely separated pathologi- 
cal conditions. Like other common manifestations, for example 
fever, its occurrence means very little in itself, and only comes to 



XERVOUS DISEASES 593 

have a definite pathological connection when we distinguish its 
causal relations and the relative importance which they bear to 
the health of the patient. 

Causes. — One of the most important factors is the age of the 
child : the younger he is, the greater is his liability to have con- 
vulsions. Leaving out of account any discussion of a possible 
convulsion-centre, we know that the development of the nervous 
system in infancy is partial and unbalanced, that all its elements 
are not present, and our experience demonstrates every day that 
full control over such undeveloped tissue is not to be expected or 
found. At such age any predisposition toward cortical irritation 
may find its 'expression in attacks whose severity is at times quite 
out of proportion to the immediate factor that started the seizure 
in motion. Under these circumstances reflex disturbances may 
be of the utmost importance. Such disturbances may include 
widely separated conditions : irritations of the skin, nasal obstruc- 
tions, a tight or adherent foreskin, the presence of intestinal para- 
sites, even possibly a difficulty in cutting teeth. All these items 
are of variable importance, and some of them — notably the erup- 
tion of the teeth — may be of very slight value or of rare occur- 
rence. One must keep in mind that the child represents a phase 
in development, rather than a fixed state. His nervous system is 
gradually evolving into a well-poised functional activity. But in 
the condition of unstable equilibrium which is natural to the 
infantile brain, a small weight in one direction or another is 
sufficient to alter the balance. 

Another instance of variable but real influence lies in disorders 
of the gastro-intestinal canal. There is no doubt that in the 
majority of cases this is more or less directly the cause. The dis- 
order may consist of indigestion or fermentation of food, with or 
without the absorption of toxic products. Doubtless in all cases 
some form of toxemia or allied condition is at the root of the 
trouble. A related cause is the intoxication that accompanies 
acute infectious disease of microbic origin, such as measles, scarlet 
fever, lobar pneumonia, pertussis, malaria, chicken-pox, and others. 
In further cases a poison, whether it is organic or mineral, may 
excite the attack. Rarer conditions that are responsible for the 
eclamptic seizure are trauma, neoplasm, abscess, haemorrhage, and 
hyper asmia of the brain. Sometimes one of these may start from 
a far-removed source, as hyperemia from rickets, or capillary 
2q 



594 THE MEDICAL DISEASES OF CHILDHOOD 

haemorrhages from scurvy. Finally the convulsions may be of 
epileptic or unknown origin, or may accompany enlargement of the 
thymus gland. Most instances occur before the third year of age. 

There is no characteristic set of lesions that fits all cases. In 
some autopsies there have been cerebral congestion (doubtless 
preceded by anaemia) and meningeal hyperemia ; there may be 
haemorrhages of various sizes in the cortex, and in the viscera 
evidences of deficient aeration. 

Symptoms. — The convulsive fit may be partial or general ; 
the first occurs as a rule with organic changes in the brain, the 
second commonly is functional. Usually there is a sudden loss of 
consciousness which may be complete or incomplete. Sometimes it 
is preceded by a cry and followed by convulsive turning up of the 
eyes, and occasional movements of the bowels and bladder. The 
hands become clinched, the thumbs turned in, wrists and elbows 
flexed, and the legs stiff. The body may be still or rigid, or 
arched, and in the last case the head and neck seek to partici- 
pate in the curve. The spasm involves the whole body, so that 
the muscles of respiration are temporarily fixed, and for the time 
the patient ceases to breathe, and turns blue. The color is 
noteworthy, because previous to the attack the skin is white and 
afterward it is flushed. The eyes are open, but the pupil does 
not react. Then the tonic convulsion, after a short duration, 
becomes resolved into a number of diminishing clonic spasms, and 
finally the fit passes away. It is succeeded by a period of stupor, 
or somnolence, that varies in length. 

Treatment. — As soon as one sees such a case, one should apply 
dry heat to the body, cold to the head, and then administer an 
enema to empty the bowel. In the convulsions which occasionally 
occur in the acute fevers during a time of high fever, the dry heat 
may be changed to a warm bath. If the pyrexia is extreme, the 
temperature of the water may gradually be lowered until it is a 
few degrees below the normal heat of the body. The convulsion 
itself is best quieted by inhalations of chloroform, and in some 
cases amyl nitrite. After the child has recovered, the gastro- 
intestinal track should be emptied by small and frequently re- 
peated doses of calomel followed by a saline cathartic. To 
counteract any convulsive tendency that may remain, one may 
prescribe bromide of soda in large doses, or chloral, or antipyrine. 
The latter two drugs should be combined with a cardiac stimulant. 



NERVOUS DISEASES 595 

The cause must be carefully sought for and, if possible, cor- 
rected. The diet especially must receive scrupulous attention, 
and the parents should be instructed concerning the importance 
which an unhealthy state of the stomach and intestines bears to 
convulsions. 

The use of morphine by mouth or hypodermatically is not 
often necessary, and in most cases should be put aside. Never- 
theless, some competent observers have used it. If it must be 
employed, hypodermatic injection is the best mode of administra- 
tion, a safe dose being 0.002 gramme (gr. 1-30) for a child one 
year old. 

Prognosis. — In most cases convulsions have no very serious 
import. With reflex irritations and gastro-intestinal disorders 
they pass away when the cause is removed. In the acute infec- 
tious diseases they signify a severe invasion, and in very sensi- 
tive children their effects as well as their occasions are generally 
transitory. Nevertheless, one should be cautious in giving a prog- 
nosis until a comparatively harmless setiology is ascertained ; for 
one should always remember that the seizure may be epileptic, or 
may follow an injury or organic disease of the brain. 

Differential Diagnosis. — The majority of cases, being due to 
gastro-intestinal disorders, will be preceded or accompanied by a 
corresponding history of overfeeding or bad feeding, constipation, 
nausea, vomiting, and anorexia, and usually have some pyrexia. 
In the cases associated with acute infectious fevers, the tempera- 
ture is high, the prostration is apt to be marked, and often pro- 
dromata may be made out. Convulsions with brain disease are 
usually not accompanied by pyrexia, are apt to recur, and gen- 
erally are followed by focal manifestations. In epilepsy the 
attacks are repeated from time to time, there is no pyrexia, there 
may be an aura, a cry, biting of the tongue, so that if there is 
froth at the mouth it is blood-stained. An examination of the 
urine will show whether there is a nephritic element in the 
disorder. 

Epilepsy 

This disorder, the old-time morbus sacer, is less often seen in 
childhood than is usually supposed, and before puberty it is not 
by any means a common complaint. Like the ordinary " convul- 
sions " of infancy it doubtless is merely a symptom of some as yet 



596 THE MEDICAL DISEASES OF CHILDHOOD 

unknown brain-condition. Its causes outside of injury, malforma- 
tions, hereditary predisposition, tumors, and disease of the brain, 
are likewise unknown. It is believed that certain reflex and 
toxic conditions, such as auto-intoxication from the gastrointes- 
tinal canal, may have a predisposing effect. Characteristic lesions 
and pathology have never as yet been ascertained, although many 
theories concerning them have been enunciated. Since these are 
matters of conjecture, they need not be touched upon. 

Symptoms. — The seizures are usually divided according to 
their duration and severity into two classes, called petit mat and 
grand mat. The first named consists of slight, convulsive move- 
ments which last for a few seconds or half a minute. There is 
commonly no premonitory sign, and after the attack the child may 
be dazed and stupid. In other cases the only evidence of the 
seizure is a momentary loss of consciousness, a momentary stop- 
page of continuous speech or action, with a feeling of being 
stunned, of some confusion, of dizziness, or of fainting. Grand 
mal is much more distinctive and lasts for a much longer time, in 
some cases even as long as twelve or fifteen minutes. It is often 
preceded by a premonitory symptom, called an aura. This may 
be sensory or motor ; in the one case there is a sudden and inex- 
plicable sense impression, such as a certain smell, taste, sound, 
flash of light, muscular sensation or disturbance ; in the other it 
consists of some spasmodic movement of a part of the body. The 
attack itself is often preceded with a cry, and begins with a con- 
vulsion which may be partial or general. The child falls to the 
ground in unconsciousness, and the tonic spasm gradually changes 
to clonic vibrations which gradually decrease and fade away. The 
face is pale, but slowly becomes cyanotic, and later is flushed. 
The eyes are open, the pupils are dilated and do not react to light. 
The set jaws may have caught the tongue between the teeth as 
they become clinched, and the resulting haemorrhage will stain the 
froth which sometimes forms at the lips. The head may be drawn 
back or to one side, the elbows and wrists are flexed, the legs are 
rigid, and the respiratory muscles are set in spasm. There may 
be involuntary passage of urine and faeces, and the reflexes are 
often diminished. After the attack has passed, the patient is 
confused and drowsy. 

Among the most important symptoms or after effects of epilepsy 
are the psychical states which it may induce. These, broadly 



NERVOUS DISEASES 597 

stated, are any abnormal deviation from ordinary manifestations 
of healthy, cerebral action. They include any degree of insanity, 
lack or distortion of memory, perverted moral sense, delusions of 
persecution, hallucinations, mania, chronic intellectual deteriora- 
tion, and a host of abnormal or unnatural acts. The epileptic 
should be regarded as a potential infringer of any normal rule of 
conduct, feeling, or thought. 

A rare form of epilepsy, called "procursive," in which the 
attack consists of or is preceded by violent attempts to run for- 
ward or backward, may for the sake of completeness be mentioned. 
A doubtful form is the so-called "masked epilepsy," where the 
convulsion is replaced by a momentary psychosis. In the excep- 
tional cases, where one convulsion follows rapidly on the heels of 
another, we have the grave condition called epileptic status. It 
should be mentioned that seizures may occur at night and leave 
no evidence excepting, possibly, a bloody stain on the bed-clothes, 
or the results of loss of rectal and vesical sphincter control. 

Treatment. — Epileptics, if they are able to select their place 
of residence, should not live in a large city. A wisely regulated 
life in the country, as has been demonstrated in the experience of 
the Craig Colony, may do much to remove causes of irritation. 
It is of the utmost importance that the diet, occupation, exercise, 
and general life be regulated in the most careful manner. Such 
oversight is of as much importance as specific, medicinal treat- 
ment. For the latter purpose the bromide of soda or the com- 
bined bromides of soda and ammonium are the most useful 
remedy. It is considered good practice to give the drug in large 
quantities shortly before an expected attack, while in the inter- 
vals the amount is reduced. In all cases it should be well diluted. 
During a paroxysm all that one need do is to give inhalations of 
nitrate of amyl or chloroform, and to put a cork or similar article 
between the teeth to preserve the tongue from being bitten. 

When the epilepsy is due to neoplasm of the brain or trau- 
matic depression of the skull, much good may be obtained by surgi- 
cal means which seek to remove the irritation. In some cases, 
however, the benefits are not permanent. 

Prognosis. — It is very seldom 'that epilepsy involves danger 
to life. Nevertheless cases of cerebral haemorrhage, of death from 
asphyxiation due to spasm of the respiratory muscles, or even of 
rupture of the heart muscle, have occurred. Such cases, however, 



598 THE MEDICAL DISEASES OF CHILDHOOD 

are exceedingly unusual. A more constant menace is the ineffi- 
ciency which the infirmity puts upon a child : he may not be alone, 
his ordinary vocations and avocations are limited, and the possi- 
bilities of a satisfactory development are lessened. In addition, 
his intellectual vigor and control are apt to be lessened, and a 
pathological condition of mind is possible at any time. 

Differential Diagnosis. — In most cases the only question 
involved is whether the seizures are of traumatic, organic, or 
reflex origin. Rarely is there a question of identity ; for the 
symptoms are so marked and characteristic that continued repe- 
tition of them gives sufficient opportunity for careful observation. 
The attacks which are caused by brain lesion are apt to be partial 
and focal ; but each case must be carefully judged by itself, 
according to the manifest symptoms. Those which depend upon 
a reflex origin disappear or are greatly improved when the cause 
of such irritation is removed. The traumatic cases give a history 
and'show the evidences of the injury. Usually it is not difficult 
to exclude uraemia and hysteria on the facts of the history. 

Chorea 

Chorea, chorea of Sydenham, chorea minor (in contra-distinc- 
tion to the hysterical chorea major), and St. Vitus's dance are the 
names given to a neurosis of childhood that has irregular and 
involuntary twitchings of one or more parts of the body as its 
principal characteristic. It occurs most frequently at and under 
the age of puberty, and may even be congenital. 

Causes. — Its causation has been a matter of much dispute. 
It has been put among the hereditary diseases, it has been at- 
tributed to fright, to reflex irritations, to conditions involving 
imperfect aeration of the blood, to exhaustion, and to the rheu- 
matic diathesis. The growing opinion of to-day tends to empha- 
size the connection with rheumatism. Chorea certainly is asso- 
ciated in the majority of cases with rheumatic manifestations, 
such as articular pains, "growing pains," endocarditis, pericar- 
ditis, subcutaneous nodules, erythema nodosum, or a family ten- 
dency. These symptoms may*precede, accompany, or follow the 
chorea. An additional fact of importance is that the only other 
acute disease with which chorea is connected is scarlet fever, 
which in turn is closely associated in some cases with a rheumatic 



NERVOUS DISEASES 



599 



sequel. Future investigation will doubtless prove the intimacy 
in aetiology of chorea and rheumatism ; even more, it may demon- 
strate that chorea is nothing more than a rheumatic manifestation, 
and that the other factors which were formerly considered causa- 
tive are no more than coincidental or predisposing. Girls are 
oftener attacked than boys. 



PULSE 


RESP. 


TEMP. 


1 


2 


3 


4 


5 


6 


7 


8 


9 


10 


n 


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170 


70 


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108 


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107 


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120 


45 


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39.4 


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PULSE, RESPIRATION AND TEMPERATURE CHART OF CHOREA, LOBAR-PNEUMONIA. 

HYPERPYREXIA, DEATH. 

AGE, 6 YEARS. 



PULSE, 



respiration __.__, 
Fig. 121. 



TEMPERATURE 



There are no known and characteristic lesions of constant 
occurrence. 

Symptoms. — The twitchings of the affected parts are irregu- 
lar, spasmodic, uncontrollable ; but they subside during sleep. 
While any part of the body may be affected, the muscles of the 
face, arms, and hands are the seats of election. A noteworthy 



600 THE MEDICAL DISEASES OF CHILDHOOD 

fact is that attempts to control the neurosis by the exercise of the 
patient's will-power result in a possible momentary quiet which 
is promptly followed by exaggerated movements. The twitch- 
ings are not constant in any except very rare cases, but occur in 
gusts or flurries. Usually they are not profound, although occa- 
sionally one may see a child who is unable to sit or stand up on 
account of the disturbance which they create. In most instances 
they may be noticed as an inability to keep the face quiet, to pro- 
trude the tongue easily and evenly, or to execute purposive 
movements with cleanness and celerity. Sometimes a group of 
muscles is affected, or a localized part of the body ; the involve- 
ment of half of the body has produced the name hemi-chorea. 
In all cases there is apt to be some weakness of the affected mus- 
cles which in unusual instances may be so severe as to simulate 
paralysis. These children have poor mental control, are irritable, 
hysterical, and easily excited, and bear restraint poorly. Very 
commonly they are anaemic, insufficiently nourished, have head- 
aches, deficient appetite, and a tendency to functional disorders of 
the gastro-intestinal system. If complicating diseases occur, they 
are apt to run a much more severe course than otherwise. Speech 
may be sufficiently affected to produce a dysarthria, or the chorea 
may be laryngeal and characterized by peculiar, barking explo- 
sions of sound. The urine has an excess of urates and phosphates, 
the tendon reflexes are diminished, and electrical stimulation of the 
muscles produces overexcitation. A very significant fact is the 
frequent occurrence of a heart murmur that is usually indicative 
of endocarditis, but which occasionally may be hsemic. Other 
rheumatic manifestations of rheumatism, such as articular pain, 
" growing pains," subcutaneous nodules, may also be present. 

Treatment. — The best thing that can be done for these chil- 
dren is to confine them to bed, at the same time providing for the 
administration of nutritious and easily digested foods, warm baths, 
an active condition of the bowels, and general massage. The 
more complete and continuous the rest, the sooner will the 
child recover. If this " rest-cure " is faithfully carried out, there 
will, in many cases, be little necessity for medication. Of all the 
drugs employed arsenic is the surest to give good results. It 
may be prescribed in the form of Fowler's solution, and given in 
increasing doses, dissolved in an alkaline water. A good method 
of administration is to begin with four or five drops three times a 



NERVOUS DISEASES 601 

day ; each succeeding day should increase each dose by one drop, 
until from fifteen to twenty drops are given at a time. It is then 
wise to begin at a smaller number, and again increase the amount. 
Usually a combination of the rest-treatment and arsenic will be 
efficient. At the same time the condition of the stomach and the 
conjunctivae should be watched in order to guard against cumula- 
tive and poisonous effects. As the child becomes quiet, it may be 
necessary to treat complicating symptoms of anaemia, endocarditis, 
gastro-intestinal disorders, or malnutrition. 

Prognosis. — The outlook is good and recovery may be pre- 
dicted m almost all cases, except where complicating symptoms or 
diseases are grave enough to endanger life. It is impossible to 
foretell the probable duration of the disease. At the same time 
the parents should be informed that the attacks are liable to 
return, especially if the patient is allowed to fall back into a poor 
condition, or is permitted to undergo much exposure. A very few 
cases run a chronic course. 

Differential Diagnosis. — There may be an hysterical imitation 
of chorea which is at times deceiving. It may be distinguished 
by its slower action, longer intervals between paroxysms, its more 
rhythmical character, and the presence of other signs of hysteria. 
Mere " nervousness," general convulsive tic, can be differentiated 
by its occurrence in periods of rest rather than during voluntary 
movements, by absence of awkwardness in action or muscular 
weakness, and finally by a chronic course. The choreiform move- 
ments, or hemi-chorea, that may follow hemiplegia have slow, 
irregular motions on voluntary exertion rather than spasmodic 
twitchings ; moreover, there is a history of some organic lesion. 
The disorder should not be called choreic. 



Teta^ty 

This disease, called also tetanilla and pseudo-tetanus, occurs 
under a large variety of predisposing or causative circumstances. 
One of its most frequent methods of occurrence in children is 
during or after conditions of malnutrition or exhaustion. Such 
conditions may be rachitic, gastro-intestinal, or convalescence after 
acute disease. Bad food and bad hygiene may predispose it, 
and in general one may say that whatever destroys the normal 
equilibrium of the body prepares the way for an attack of this 



602 THE MEDICAL DISEASES OF CHILDHOOD 

disorder. The extirpation of the thyreoid gland produces typical 
symptoms, although the method of the production is not under- 
stood. The lesions and pathology are not known. 

Symptoms. — The attack begins by a sensation of an indefinite 
disorder in the extremities, followed by a diffuse tingling and 
fragmentary painfulness. This is succeeded by a growing rigidity 
of the muscles, which finally develops into a tonic spasm that may 
be so severe as to prevent both voluntary and passive motion. 
The hands are oftener and sooner affected than the feet. The flexor 
muscles are the principal sufferers. The fingers assume the writer's 
or accoucheur's position so regularly as to give by this means a 
characteristic sign. In mild cases as little as one finger may be 
affected ; but in severe attacks the forearm may be flexed at the 
elbow, and the arm adducted to the shoulder. In the same man- 
ner the toes become flexed, the arch of the foot cupped, and the 
legs extended to the thighs. These spasms may last for minutes 
or hours, may suddenly cease, or continue to recur. While they 
last the muscles are hard and tender on pressure, but in the intervals 
they may be no more changed than to feel somewhat stiff and sore. 
In unusual cases the trunk, neck, and face may be involved, with 
a resulting interference with the muscles of respiration, of the 
eyes, tongue, and the powers of articulation and deglutition. The 
patient may feel a constant desire to urinate, without being able 
to gratify the desire. There is commonly a deficient muscular 
sense, and the patient, if he is old enough, speaks of feeling as 
if he were walking on a velvet-like fabric whenever he moves. 
During the attacks there may be an elevation of temperature, 
sweating, headache, dizziness, and a sensation of hearing a roar- 
ing noise. The involved muscles are symmetrically situated, 
and often present a fibrillary twitching. 

A noteworthy observation, called after the name of its maker, 
Trousseau, is the fact that a spasm may be caused during an 
interval, or exaggerated, if it is present, by pressing upon or con- 
stricting an affected part. This sign is not invariably present, 
but it is often supplemented by the so-called Chvostek symp- 
tom, which consists of an unusual sensitiveness of the nerves to 
mechanical irritations, such as light blows. It is also not inva- 
riably present, and may be best obtained in the face by striking 
with the finger, as in percussion, below the zygoma and in front 
of the ear. Erb's symptom consists in an exaggerated response 



NERVOUS DISEASES 603 

of the nerves to electrical stimulation. Both anodal and cathodal 
opening and closing contractions may be obtained with a com- 
paratively weak current. 

Vaso-motor disturbances have been observed — such as a 
puffy redness in the neighborhood of the joints, and disturb- 
ances of the hair and nails. Atrophy of the muscles and mental 
derangements have in a few cases been noticed. 

Treatment. — There is no specific treatment, although symp- 
tomatic care is usually efficient. First of all, the general envi- 
ronment must be improved. Diet, bathing, clothing, ventilation, 
and the gastro-intestinal functions must be carefully regulated, 
and when possible the patient should be removed to the fresh air 
of the country. He should under all circumstances be confined 
to bed. For the control of the spasms, antipyrine prescribed in 
connection with a cardiac stimulant will give satisfaction. Other 
useful drugs are bromide of soda, in large doses, and chloral. In 
exceedingly severe attacks it may be necessary to resort to tem- 
porary inhalations of chloroform. 

Because the symptoms of tetany have followed extirpation of 
the thyreoid gland, the plan of prescribing the extract of the 
dried gland has been proposed. The value of the method is as 
yet unknown. 

Prognosis. — Usually these cases, after a variable length of 
time, recover. There are a few fatal cases, most of which seem 
to occur in children who have a coincident complication of gastric 
dilatation. 

Differential Diagnosis. — Tetany may be confused with tetanus 
or hysteria. In the former trismus is a common and early symp- 
tom, while in tetany it is a rare and late one. In tetanus and 
hysteria there will be an absence of the Trousseau, Chvostek, and 
Erb symptoms, which, with the general picture of the disease, 
constitute an easy and ready way of marking it off from other 
complaints. 

Hysteria 

Hysteria is a functional disorder of the nervous system, whose 
manifestations are so wide and irregular that every case is apt 
to vary in some detail or other from any strictly formed t} T pe. 
It is not so commonly seen in children as in adults ; and, follow- 
ing a like rule, its frequency diminishes as we try to gather cases 



604 THE MEDICAL DISEASES OF CHILDHOOD 

from younger and younger children. The possibility of becom- 
ing hysterical seems to depend upon the disturbance which fol- 
lows a state of overpowering impressions, of being overmastered 
by some fixed idea or powerful impulse. In all cases, however, 
there seems to be a necessity of a predisposition, expressed or 
latent. Such a tendency may flow from hereditary taint, asso- 
ciation with hysterical or imperfectly restrained persons, physical 
depression or asthenia, such as might follow poorly regulated lives, 
acute or chronic diseases, injury, fright, overexertion, sexual mal- 
formations, and perversions, vicious habits — in fact, any condi- 
tion which makes for lack of nervous equilibrium. There are 
no known lesions that are characteristic of all cases. 

In mild attacks the symptoms may be of almost any variety ; 
there may be psychical, sensory, or motor disorders. In the first 
type we may see such symptoms as uncontrollable laughing or 
crying, occasionally followed by some degree of mania. In other 
cases there may be a longer period before the mania, made up of 
irritability, sleeplessness, lack of self-control, and functional dis- 
orders. In still other cases there may be cataleptic, somnam- 
bulistic, and trance-like states that may occasionally start from 
impulses which seemingly are petty. Again, there may be 
attacks of hystero-epilepsy (more properly called grand hysteria 
or hysteria major), although there is no real epilepsy present. 
In such cases there is an aura, often globus hystericus or clavus, 
in other instances ovarian or testicular pain. Closely following 
this there will be an epileptoid condition which gives way to a 
stage of "grand movement." This stage is characterized by 
violent postures or movements which may be complexly auto- 
matic, purposive, or atypical; they may even take the form of 
pronounced opisthotonos. The last stage that we usually see is 
one of delirium, in which the child cries and weeps incoherently, 
and then finally becomes quiet. 

Under the heading of motor symptoms one may include prac- 
tically every sort of clonic and tonic spasm or convulsion. These 
may vary from a mere twitching of a muscle or an extremity to 
elaborate attacks of chorea major. Under this division, again, may 
likewise be included hystero-epilepsy, whose manifestations are so 
manifold as to allow its being placed in any variety. Chorea 
major, which has no choreic symptoms, is really a partial or incom- 
plete attack of hystero-epilepsy. Among the other possible 



NERVOUS DISEASES 605 

symptoms are hysterical cough, wry neck, hiccough, laryngeal 
spasm, dyspnoea, oesophageal and gastric spasm, intestinal and 
vesical contractions, or even a pseudo-paralysis. 

The sensory symptoms include any form of increased or 
diminished sensation. Hyperesthesia is most commonly located 
over the ovaries, testicles, and spine ; and pressure over these so- 
called hysterogenous zones is capable of producing typical attacks 
of hysteria. In some children the painful areas are confined to 
one or more joints, and occasionally their ability in magnifying 
these pains into the likeness of a serious organic disease is remark- 
able. Also, anaesthesia is comparatively common, and its at} r pical 
situation is really typical. It has no respect for anatomical dis- 
tribution and may cover any spot on the surface — au extremity, a 
zone, or a half of the body. In the last-named case the anaesthesia 
is remarkably complete and may carry with it a loss of sight, 
hearing, smell, and taste on the affected side. In other children 
the blindness may be the only manifestation, or may be replaced 
by photophobia or other sense deprivation. 

Among the conditions that are seen in conjunction with hys- 
teria are various grades of anaemia, gastro-intestinal disorders, 
dilatations of the stomach and small intestine. 

Treatment. — The first and often most important step lies in 
the direction of improving the child's environment. This will 
often necessitate separation from a parent who is hysterical or 
lacking in self-control. If possible, the patient should be placed 
in charge of a relative or nurse who has the blessed gift of 
common sense, with an admixture of sjmipatlry. The child 
should be treated kindly but with firmness, and his custodian 
must be made to understand that the disorder thrives upon the 
large amount of fright, commotion, undue solicitude, and forced 
restraint which its manifestations elicit in the spectators. He 
should lead a regular life, with wisely regulated duties, exer- 
cises, and relaxations. Hydrotherapy is of great use, and the 
administration of general tonics is in all cases necessary. If 
there are any possible causative deformities, such as a tight or 
very long prepuce, or an hypertrophied pharyngeal tonsil, they 
should be rectified. 

Prognosis. — While the chances of recovery are large, never- 
theless children are apt to bear the marks of their disorder for a 
long time, as well as to preserve a tendency to repeated attacks. 



606 THE MEDICAL DISEASES OF CHILDHOOD 

This especially is true of those cases that have an hysterical 
descent or the family association of hysterical persons. 

Differential Diagnosis. — It is difficult to give an exact method 
of separating hysterical manifestations from all others. In certain 
minor degrees they are scarcely recognizable, or may be combined 
with the symptoms of organic disease in such a way that one 
must use the best judgment in drawing a line between the two. 
On the whole, one may say that by recognizing the hysterical 
stigmata, such as the physical, motor, and sensory disturbances, 
and the lack of definite or organic disease, one may arrive at a 
true view of the case in hand. It is only in the unusual case, if 
there is full opportunity for satisfactory observations, that the 
real state of affairs is hard to see. 

Headaches 

Pain in the head is a symptom that is seen in almost every 
diseased condition at some part or other of its course. The only 
safe way in which we can regard it is as a secondary matter, 
whose cause must carefully be sought for and isolated before a 
real cure can be obtained. Each observer may make his own 
classification, and one may be as good as another. The main 
thing is to insist upon a thorough sifting of the various facts in 
each case ; for the physician should never be satisfied that the 
disorder is of no importance, until he has excluded every cause 
except a trivial one. In children, even more than in adults, a 
headache may be a danger signal to inform one of a pathological 
condition, existent or forming, which may finally become of con- 
siderable importance. 

Ansemia and malnutrition are a fruitful source of headaches, 
which, if accurately located, are referred to the forehead and 
bregma. They are dull and heavy, and are apt to be most 
marked in the morning. 

Gastric disturbances are one of the commonest causes of head- 
aches in children. Usually they are frontal, but may also be 
located in the top of the head ; with them there will be associated 
other symptoms of the primary complaint. They have a ten- 
dency to recur, and also to run a course of remissions and exacer- 
bations. Their mode of causation is doubtless associated with 
the absorption of the products of partial digestion, fermentation, 



NERVOUS DISEASES 607 

and putrefaction of food stuffs. In this way they represent a 
form of poisoning, and are closely related to the so-called toxic 
causes. 

These toxic causes cover a wide range of conditions. They 
arise from the absorption of poisonous substances in the acute 
infectious fevers, ursemic conditions, malaria, and the metallic 
poisons, such as lead. Each is apt to be accompanied by other 
symptoms by which its identity can be settled. 

Disorders of the special senses, in the eyes, ears, and nose, are 
an important source. Eye-strain, and pathological conditions of 
any part of the eyes ; abscess, otitis media, foreign bodies in the 
ear, and mastoid disease ; hypertrophy of the pharyngeal tonsil, 
deviations of the septum, nasal polypi, and acute rhinitis, all these 
are able to cause headaches which are variable in location and 
degree. 

Less often in children some pathological condition of a part 
of the nervous system is at fault. Here again the range is very 
wide. There may be organic disease of the brain and its mem- 
branes, new growths, neuresthenic states, hyperemia, induced by 
fright, excitement, strain, or physical malnutrition. In this 
class one might easily include reflex conditions, such as the 
headaches which follow genital malformations or disordered func- 
tion. A tight or adherent prepuce has been known to cause 
severe pain in the head, which ceased when the glans penis was 
released. Delayed or disordered menstruation is frequently con- 
nected with headaches in young girls. 

In all these cases the syndrome must be carefully analyzed, 
and if the analysis is correct, one will at once have obtained 
diagnosis, treatment, and prognosis. The headache should be 
regarded as a secondary consideration. The primary disease is 
the main factor. 



CHAPTER XXIII 

DISEASES OF OBSCURE ORIGIN 

Diabetes Mellitus 

This disease is not often seen in children, but when it does 
attack them its course is severe and rapid, and its outcome is 
commonly fatal. Its causes are unknown ; but I remember two 
cases, both in girls, where the condition occurred after acute 
disease of a severe type. Boys seem, according to statistics, 
to be somewhat oftener afflicted than girls. In some families 
there seems to be a marked hereditary influence, on account of 
which the disease has a liability to break out during some period 
of profound physical exhaustion. 

The symptoms appear in the form of polyuria, polydipsia, 
disorders of the gastro-intestinal track, and progressive loss of 
flesh and strength. The child complains of many nervous symp- 
toms, of irritability, lack of concentration, variable appetite, and 
noteworthy change of disposition. The urine may have a specific 
gravity of from 1.020 to 1.040, the increase in quantity is large, 
and it may contain indican, acetone, and diacetic acid. There 
may be albumin, or even casts, which usually are the result of 
a superimposed nephritis. Coincidentally there may be small 
quantities of diacetic acid and acetone in the blood. 

The treatment is unsatisfactory, and consists of strict dietetic 
regulation, with the use of large doses of strychnine. The 
bichloride of mercury has been advocated in New York for this 
disease ; but the results are not encouraging. Also, the use of 
opium has been advised, and temporary amelioration of symptoms 
has in some cases followed it. But we have no reason to believe 
that the drug will make a definite cure. With the regulation of 
the diet according to the rules which we observe in treating 
adults, we combine a conscientious supervision of the hygiene, 
exercise, studies, and general mode of life. 

The prognosis is bad, and commonly death results from 
gradual asthenia, diabetic coma, or intercurrent disease. 

608 



DISEASES OF OBSCURE ORIGIN 609 

Rheumatism 

Rheumatism in children is a widely prevalent disease, much 
more so than is commonly believed. It occurs in such varied and 
at times obscure forms that its true nature is commonly overlooked. 
One more often hears of some of its manifold manifestations, such 
as endocarditis, pericarditis, " growing pains," tonsillitis, torticollis, 
and chorea, than of the typical arthritis that is so commonly seen 
in adults. The cardiac disorders in particular are so prominent 
and frequent, they exert so overmastering an influence in the 
course and outcome of the disease, that one is often in doubt 
whether they or the arthritic symptoms should be regarded as the 
typical characteristics of the sickness. 

Causes. — The tendency of modern research is all in the 
direction of placing both on the plane of important but not abso- 
lutely essential symptoms. One cannot as in former times regard 
rheumatism as a " blood " disease, and progressively there is more 
and more difficulty in believing that it is a nervous or chemical dis- 
order. Uric and lactic acids, while covering a multitude of 
diagnoses, cannot longer be held responsible for rheumatism, any 
more than the free melanin developed in the course of malaria can 
be regarded as the essential cause of paluclism. On the other 
hand, the more one observes the disease the more is one struck by 
its resemblance to an acute infection of bacterial origin. It occurs 
in waves, as enteric fever or scarlet fever does ; a house in which 
a rheumatic person has lived is very apt to have other cases of the 
same sickness ; its peculiarity of attacking a viscus that is 
removed from the ostensible seat of disorder is striking ; and a 
person who is in poor physical condition, whose environment pro- 
vides poor air, food, and habitation, is more apt to contract the 
disease than a well cared for child. Its more frequent occurrence 
at one time of the year, as in late autumn and early winter, than 
at others creates a still further resemblance. The fact that the 
disease seems to run in an hereditary strain through certain 
families should be regarded in the light of a predisposition, such 
as exists in tuberculosis. Under these circumstances a child of 
rheumatic parentage acts as a fertile culture medium for the 
germ ; his body welcomes, especially in conditions of debility, 
instead of fighting against the contagion. It is a noteworthy fact 
that where both parents are rheumatic, the liability of the child 

2r 



610 THE MEDICAL DISEASES OF CHILDHOOD 

to contract the disorder is much greater than if only one parent 
is tainted. 

Rheumatism in the earliest years of life affects boys oftener 
than girls ; from five to ten years the rate is nearly even ; from 
ten to fifteen years girls are attacked more frequently than boys. 
The degree of severity seems to be about the same in both, and 
complicating conditions show no partiality for either. The 
explanation of these changes is hard to give, but the facts 
themselves are interesting. 

Lesions. — The changes which are regularly present are not 
startling, and it is only in marked cases that they become note- 
worthy. In the joints the synovial membranes may be congested 
and infiltrated with lymphoid cells, and the superficial layers may 
be in a condition of desquamation and proliferation. There may 
be an effusion of serous fluid into the cavity, in the walls of which 
one may discern fine hemorrhages. Fibrous tissues about the joint 
become infiltrated with products of inflammation, so that they are 
thickened, nodular, and hard. In some cases this thickening and 
hardening process attacks the fascial tendons entirely outside of 
and beyond the joint, and may especially in cases of serious 
cardiac complication be easily felt through the skin. These 
nodular formations are closely allied to the neoplastic roughnesses 
on an inflamed heart valve or the pericarditis of this disease. 
Endocarditis and pericarditis are very common, and are marked 
by interstitial changes. These lesions of the latter condition may 
extend to the connective tissue of the anterior mediastinum, so 
that a mass of matted adhesions may be formed which seriously 
impedes the growth and development of the immature heart. 
The ordinary complications and sequels of cardiac disease may 
follow. 

Symptoms. — The attack may begin very quietly, with indis- 
position, restlessness, and slight or moderate fever. There is 
often pain in one or more joints, but at times it is so slight as to 
attract little attention ; in some cases only one joint is attacked, 
and the pain may remain there or flit about to other joints. Thus 
the knees, hips, ankles, feet, elbows, and shoulders may be involved, 
together or separately. Occasionally we can discern no more than 
stiffness and a slight soreness in the tendons of the muscles, or 
muscular spasm may be so prominent as to overmaster the other 
objective signs. In some of these cases the child is with difficulty 



DISEASES OF OBSCURE ORIGIN 611 

kept in bed, and insists on being about even if in doing so he is 
forced to hobble. The temperature does not often rise beyond 
39° C. (102.2° F.), the stomach and intestines are not seriously 
disturbed, and the patient does not seem seriously sick. 

On the other hand, one occasionally, most of all in older chil- 
dren, sees sharp and violent attacks where the joints are acutely 
swollen and very painful, the temperature high, the prostration 
marked. Instead of lasting for a week or two, the disease con- 
tinues for nearly a month. The heart disturbance may, from the 
first, be startling, and the anaemia may be so sudden and profound 
that its hsemic murmurs are interpreted as being caused by an 
endocarditis. This impoverishment of the blood is so character- 
istic of rheumatism that it may be noticed in the mild as well as 
in the severe cases. However, when these violent cases occur 
their course is much the same as in adults. 

The inflammations of the pericardium and endocardium as well as 
of the heart muscle are more frequent in their incidence, and pro- 
portionately severer in their course than similar attacks in adults. 
An endocarditis may be one of the first symptoms, or may come 
at any part of the disease. It commonly begins in a quiet fashion, 
and its presence may not be noticed until the heart is auscultated. 
In some cases, from its onset, there may be precordial pain, irregu- 
lar heart action, embarrassed breathing, and the characteristic 
murmur. Most commonly the mitral valve is rendered insuffi- 
cient ; but any other pathological condition may also result, and 
one or both of the other valves be simultaneously involved. The 
severity of these inflammations may cover the widest range : they 
may be merely an accentuation of the two sounds, or the second 
alone may be accentuated or duplicated, with no worse symptoms 
than thin, hard pulse, dyspnoea on exertion, slight cough, and 
nervous irritability. On the other hand, the endocarditis may 
become violent and give all the symptoms that belong to fatal 
cardiac disease. The ulcerative form is, excepting in older 
children, very rarely seen. 

Pericarditis usually appears late in the sickness, with or with- 
out endocarditis. The severer the endocarditis the greater is the 
likelihood of an associated pericarditis, and in these grave cases 
the attack may come sooner than in the mild ones. The onset in 
most children is, like that of the endocarditis, gradual ; the tem- 
perature is moderate, the pulse rapid, the heart action labored. 



612 THE MEDICAL DISEASES OF CHILDHOOD 

The pericardial friction sound is plainly heard, usually near the 
apex. If effusion into the pericardial sac takes place, the area of 
cardiac dulness becomes correspondingly enlarged. The growth 
of adhesions may be considerable, so much so, in fact, that the 
ordinary signs are changed and made difficult of recognition. 
Nevertheless, the rapid, irregular, and straining heart action 
remains, no matter what remedies are administered. In some 
children the result may be obliteration of the whole pericardial 
cavity, the heart may be bound to the neighboring tissue, and the 
fibrosis may extend over a part of the anterior mediastinum. In 
this way the mediastinal glands, the pleura, and pericardium may 
become so changed and connected that normal action of both heart 
and lungs is seriously, or even fatally, impeded. In such severe 
cases of pericarditis and endocarditis there is generally an inter- 
stitial myocarditis as well. The added symptoms of weakened 
and irregular heart action are not plainly discernible, and the 
condition is usually ascertained on post mortem examination. 

In these cases of grave cardiac changes one sometimes meets 
with the development of fibrous nodules near the skin in the 
fibrous tissue of fasciae and tendons, and on autopsy they may be 
found in the periosteum, and sometimes on the pericardium. I 
have seen them along the spine, on the ankles, backs of the hands, 
and on the knees ; also they may appear on the elbows and back 
of the head. They may be as small as small seeds, or as large as 
a small nut. They last for a variable time, from a few days to 
months. They give no especial symptoms, and their importance 
lies in the fact that they indicate a tendency to serious cardiac 
involvement. Such cases, more than all others, should be treated 
with the utmost caution. 

The connection of chorea with rheumatism is a very close one 
— so close, in fact, that many observers believe chorea to be essen- 
tially rheumatic in its origin. Not only is rheumatism in children 
often followed by chorea, but also, on the other hand, chorea is 
commonly the forerunner of an attack of rheumatism. And even 
when it occurs without arthritic manifestations, its connection 
with cardiac lesions is striking enough to attract attention. The 
relationship between these three groups of symptoms is remark- 
able, so that one may safely regard a rheumatic child as potentially 
choreic and cardiopathic. The general predisposition so plainly 
runs through families that on seeing: a marked case of chorea, one 



DISEASES OF OBSCURE ORIGIN 613 

may expect in other children of the same family cardiac or rheu- 
matic tendencies. In these cases the degree of anaemia is 
greater than in the milder ones ; but all rheumatic children may be 
said to suffer in some measure a deterioration in the quality of 
the blood, whose signs are like those of simple secondary anaemia. 

Another manifestation of the rheumatic disposition that is 
doubtless allied to the fibrous infiltrations of the tendons is the 
spasmodic torticollis which one occasionally sees. It may come 
without warning, or with a rheumatic attack. The sterno-cleido- 
mastoid muscle is put on the stretch, sometimes to a very painful 
degree, so that the head is bent to the opposite shoulder. This is 
especially likely to happen in those children who easily suffer from 
inflammation of the tonsils and pharynx, which in itself may com- 
monly be looked upon as another indication of rheumatism. 

An unexplained phenomenon in this disease is the appearance 
of purpura hsemorrhagica. This may possibly be an indication of 
hemophilic tendency, a simple purpura, or some special and severe 
form of infection which is peculiar to rheumatism. Doubtless one 
form exists in one child and another in the next. But there is 
good reason to believe that some cases have a distinct connection 
between the inflammation in the joint and the hoemorrhagic erup- 
tion that is generally located near to it. The lower extremities 
are affected more often than other parts of the body. 

The only other skin eruption which we meet in rheumatism is 
erythema. The ordinary forms are all represented, and stated in 
the order of frequency would read : papulated, marginated, urti- 
carious, and nodular. They may accompany cases in which the 
articular symptoms are predominant and, on the other hand, may 
appear where the cardiac disorder is supreme and the articular 
trouble slight. They have no especial significance. 

Treatment. — At the first indication of rheumatism the gas- 
trointestinal track should be emptied by means of small and 
repeated doses of calomel, followed by the citrate of magnesia. 
The affected joints may be wrapped in cotton-wool, and, if the 
pain is great, protected by some sort of cradle to prevent pressure 
or injury from without. A few doses of salophen may be rapidly 
administered to relieve the pain ; when the child's suffering has 
abated, this drug may be replaced by the natural oil of winter- 
green given on a lump of sugar, salicin, or the salicylate of soda. 
In extremely painful cases it may be necessary to give a few doses 



614 THE MEDICAL DISEASES OF CHILDHOOD 

of opium to quiet the patient. In children, even more than in 
adults, it is absolutely necessary to reduce the suffering as quickly 
and as thoroughly as possible. They, much more than their 
elders, are injured by the restlessness and exertion which come 
with suffering. It is in this way that cardiac disorders, to which 
they seem to have a strong tendency, are invited. Under such 
circumstances measures, which otherwise might not be looked 
upon as necessary or even justifiable, become highly desirable. 
The value of opium or morphine is often thus indicated, most of 
all if endocarditis or pericarditis is imminent or existent. With 
this complex of symptoms there is no other drug of greater 
importance. Such a cardiac inflammation may, in addition, neces- 
sitate the application of an ice bag to the pericardium and the 
use of digitalis or strophanthus. 

The child should receive a sponge bath every day, and if the 
temperature is high, he will be benefited by being placed in a bath 
of an approximate temperature of 37.5° C. (99.5° F.), which is 
rapidly reduced to from 16° to 19° C. (60.8° to 66.2° F.). 
During this bath the surface of the bod} r , excepting the inflamed 
joint or joints, should be briskly rubbed with the hand. The 
diet should be milk, meat soups, and beef extracts ; and a suffi- 
ciently large quantity of pure water must be given. 

Until recovery is assured, or at least until all tenderness has 
left the joints and dangerous cardiac symptoms have disappeared, 
the child must be kept in bed. After this period has passed, he 
may be taken into the sunshine. It will then be necessary to 
treat his anaemia, to endeavor to promote compensation if he has 
had cardiac disease, and in general to build up his health and 
strength. For months after the attack he should be under medical 
supervision, even although active medical treatment be unneces- 
sary. His diet should be carefully supervised, and it especially 
should not be allowed to include more than a minimum of 
starches and sugars. 

Prognosis. — The principal danger in the rheumatism of chil- 
dren is not the joint as much as the cardiac affection. As far as 
the articular part is concerned, the outlook on the whole is not 
bad, and the cases generally recover within one or two weeks. 
A disturbing factor, however, is the well-marked tendency of the 
disease to recur; and the successive attacks progressively weaken 
the patient, and increase the dangers of cardiac involvement. 



DISEASES OF OBSCURE ORIGIN 615 

These dangers are very serious ones, for at any moment an endo- 
carditis that has seemed comparatively slight may burst out into 
extravagant violence. 

Differential Diagnosis. — The diseases with which rheumatism 
may be confused are scurvy, hereditary syphilis, tuberculosis, 
pyaemia, and rachitis. But none of these disorders has the com- 
bination of family and personal history, involvement of joints, 
possible endocarditis, pericarditis, chorea, tonsillitis, torticollis, 
subcutaneous nodules, and tendency to erythematous eruptions. 
The association of comparatively slight articular disease and an 
ever present leaning to cardiac disorder is in itself often diagnos- 
tic. Instances of " growing pains " come under this head, and 
should always be looked upon as likely to foreshadow serious 
trouble. Finally, one must keep in mind that rheumatic patients 
are anaemic, that anaemia is often accompanied by soft haemic 
murmurs, which one should not confuse with those of true endo- 
carditis. 

Rheumatoid Arthritis 

This is a very rare disease in children, the cause of which is 
unknown. Most of the few cases on record have occurred in 
England and on the Continent of Europe. Almost all of them 
were in children under six years of age. 

There is a chronic swelling of the joints, which gradually 
become anchylosed. The synovial membranes and ligaments 
are injected and thickened, the capsule may be swollen, and the 
synovial fluid may be increased in quantity. The spleen and 
lymphatic glands are enlarged as the result of simple hyperplasia, 
and may show minute ecchymoses. 

The disease begins in a slow and gradual fashion, with slight 
or no fever. There may be some tenderness in the joints, which, 
however, is practically never very great. The joint gradually 
increases in size, at the same time slowly losing its power of 
movement. The disease very slowly involves the knees, elbows, 
wrists, fingers, toes, and cervical vertebrae. The articular en- 
largement is smooth and regular, therein differing from the 
irregularly knobbed contour of the adult form of the disease. 
When these joints are moved, one can feel the creaking and rub- 
bing of the tendons and cartilages. 



616 THE MEDICAL DISEASES OF CHILDHOOD 

As the child becomes helpless and is confined to bed, the mus- 
cles become atrophied, weak, and flabby. In some cases muscular 
contractures are formed. The glands are hard, swollen, not sen- 
sitive. The spleen is enlarged, there may be inflammations of 
the pleural and pericardial sacs. There is a marked loss of flesh 
and strength, a distinct anaemia, and a moderate febrile movement. 
The disease runs a sIoav and sure course, with periods of remis- 
sions and exacerbations. 

There is no specific treatment, and all that one can do is to 
relieve the symptoms. Death comes from some intercurrent 
disease. 

Another form of rheumatoid arthritis, that is quite similar 
to the disease in adults, may occur in older children. It needs 
no special description in this place. 

Acute Arthritis of Infants 

A form of arthritis, which is really an acute purulent disease of 
the bone, occurs in young infants as the result of pyogenic infec- 
tion contracted through the umbilicus, a wound, or after the acute 
infectious fevers. It may attack any of the articulations, but 
oftenest affects the hip, knee, shoulder, wrist, elbow, ankle, the 
fingers and toes. The lesions are what ordinarily occur in puru- 
lent synovitis. The symptoms are the regular ones of pus infec- 
tion, — a chill, irregular fever, prostration, local pain, heat, and 
swelling. The formation of pus leads to the sensation of deep 
fluctuation ; and if the abscess is not opened the fluid, after 
destroying the joint, breaks through the capsule into the sur- 
rounding tissue, from which it may finally rupture. 

The disease is really a surgical one, and demands the usual 
surgical treatment of any abscess cavity. The chances of life 
are very poor, as they are in all cases where infants have to con- 
tend against a pysemic infection ; in the cases that survive, the 
only hope resides in an undelayed operation. 



CHAPTER XXIV 
INFLAMMATIONS OF THE MIDDLE EAR 

Causes. — Otitis media is a common trouble in infants and 
children ; the fact that it does not always end in a discharge 
from the ear helps to obscure its existence, and prevent a diag- 
nosis. Evidence of this lies in the man}' cases where the phy- 
sician learns with surprise that serum or pus has suddenly 
appeared, usually attended by relief of the symptoms which 
he had believed to be due to other causes. In some cases the 
disorder develops without any known reason ; in others it accom- 
panies or follows complaints that often do not at all affect the 
ear. The lack of inevitable sequence is thus the main excuse 
for a failure to appreciate the facts of the situation. While 
injuries, blows, and foreign bodies can set up such an inflam- 
mation, they are, nevertheless, comparatively rare. Usually the 
trouble begins by extension or infection from the nose and 
Eustachian tube, and abnormal conditions in these parts must 
be regarded as the primary factor. Thus the various forms of 
rhinitis, of pharyngitis, of amygdalitis, of laryngitis, and hyper- 
trophy of the pharyngeal tonsil are the real responsible elements, 
aided by the size, direction, and patency of the youthful Eustachian 
tube. These diseases may exist alone, or may accompany or follow 
some of the acute infectious diseases, such as measles, scarlet fever, 
epidemic influenza, diphtheria, enteric fever, and pneumonia. 
When the inflammation begins it may be simple or, in the pres- 
ence of the proper micro-organisms, may become purulent. Either 
may be acute or chronic. 

Lesions. — Commonly the changes begin in the mucous mem- 
brane of the tube, which becomes reddened, congested, and swol- 
len. The process then extends into the ear, where, in addition, a 
small amount of serum or mucus is held. The swelling and 
consequent occlusion of the tube prevents an escape in that 
direction, so that the fluid is retained, with the natural results 

617 



618 THE MEDICAL DISEASES OF CHILDHOOD 

of fever and pain. When this fluid becomes contaminated by 
pyogenic organisms, pus is formed. The symptoms become more 
marked, especially in the face of the developing lesions. The 
pus may rupture through the membrane, as in an abscess forma- 
tion; or, following the eccentricities of such processes, it may 
burrow through adjacent structures. Thus, in a few rare cases, 
it has made its way along the cartilages, and then through the 
skin. The serious results of purulent otitis may be mastoiditis, 
purulent inflammation of the ossicles and bony walls of the ear, 
of the petrous bone, meningitis, cerebral and cerebellar abscess, 
thrombosis and of the intra-dural sinuses. 

Symptoms. — In the simple form the signs may not be very 
pronounced. There will be an irregular but moderate fever, pain 
in the ear on pressure or without pressure, headache, malaise, and, 
if a synchronous disease exists, an exaggeration of the subjective 
symptoms of that disease. In some cases no change in the tympa- 
num can be noticed ; in others it is congested, lacking its normal 
hue, and to a small extent bulges out. After a few hours or days 
a thin serous discharge may be noticed, and with its appearance 
the pain and fever disappear. The child, even in slight attacks, 
is left weak and exhausted. If the amount of fluid is large, the 
pain and pressure symptoms are greater. 

In the purulent inflammation the symptoms are much severer. 
The disease may begin with a chill, there may be nausea and 
vomiting, and convulsions and delirium are not rare. The tem- 
perature runs higher, often reaching 40° C. (104° F.), and the 
pain is keen and tearing, giving rise to a peculiarly sharp cry. 
In times of consciousness the child puts his hand to the affected 
side of the head, is unwilling to lie upon it, and fears a foreign 
touch. The whole surface around the ear is tender, especially in 
front and behind it, and abnormal sounds may be heard. Oto- 
scopic examination frequently shows a swollen and protruding 
membrane, most of all in the lower arc. Spontaneous perforation 
relieves the pain, pressure, and temperature, and either may be 
recognized directly, or may be inferred from a large amount of 
discharge, a whistling sound on blowing the nose or inflating the 
ear, air-bubbles in the canal, or pulsation of the membrane. 

The complications are always serious. Mastoiditis may be 
marked by external rupture more easily in young children than 
in adults, on account of the thinness of the one cavity, the antrum. 



INFLAMMATIONS OF THE MIDDLE EAR 619 

In most cases this does not follow; but the symptoms of pain, 
local swelling, which pushes the external ear away from the head, 
and pressure effects require treatment before they subside. In 
other cases a pachymeningitis or general meningitis may result 
from infection through the tegmen tympani ; most rarely it 
follows, as a secondary effect, some other brain disease which 
originated in the same way. These diseases are abscesses of the 
cerebrum, or cerebellum, and thrombosis of the intra-dural sinuses. 
On the other hand, the meningitis, being the first infection, may 
be followed by these other infections as secondar}^ complications. 
Facial paralysis may occur as an extension of the inflammation 
to the seventh nerve, which passes through the bony canal. The 
labyrinth is rarely involved. 

Treatment. — The stomach and intestines should be thoroughly 
emptied. A rubber bag filled with hot water should be placed 
against the ear, while the cavity of the organ may be filled with a 
warm boracic acid solution, or a pledget of cotton soaked in such a 
solution. The warmed oils, the tinctures of opium and peroxide of 
hydrogen, supplemented by the application of leeches, which were 
formerly used, are now thought to do as much harm as good, some 
by means of producing an unclean surface, others by affecting 
the integrity of the delicate epithelium. Sometimes, especially 
in mild cases, considerable relief may be obtained by the instilla- 
tion of a few drops of a one per cent solution of cocaine in boracic 
acid. But the main plan of treatment is to apply dry heat for 
the relief of pain, while the boracic solution will cleanse the 
canal preparatory to a possible paracentesis, and at the same 
time, by its soothing property, give a small added measure of 
comfort. Such a method is fully equal in efficiency to the use 
of an ice bag, the cold of which most children undoubtedly 
dislike. If the symptoms are not relieved within six hours, 
paracentesis of the membrane should be performed. No deep 
syringing is necessary, for there is always danger of thereby 
carrying a purulent discharge farther than it had hitherto pro- 
gressed. The ear may be lightly washed with a saturated solu- 
tion of boracic acid, and lightly packed with sterilized gauze for 
protection and drainage. The temperature falls almost immedi- 
ately, unless there is an involvement of the bony structure. If 
it begins to mount again, the cause must be sought in imperfect 
drainage, the pocketing of pus, or a spread of the infection. 



620 THE MEDICAL DISEASES OF CHILDHOOD 

During the whole attack the throat and the nose should be kept 
clean by an alkaline antiseptic solution, such as Seller's or Dobell's, 
used in the form of a fine spray. Complications should be treated 
according to their needs. The tendency of modern practice lies in 
the way of a comparatively early resource to surgical help, rather 
than in that of a protracted delay with its possibly serious conse- 
quences. The mastoid, however, is often tender, although there 
may be no pus ; we accordingly do no more than apply an ice- 
bag or a cold water coil. If, however, there are signs of pus 
in it, an operation should be performed without hesitation. If 
one keeps in mind the fact that all purulent diseases of the 
ear are instances of localized sepsis, the treatment immediately 
becomes plain. 

After the acute attack has passed, the child is sufficiently 
debilitated to need the systematic administration of tonics for a 
considerable time. 

Prognosis. — The simple cases are not at all serious, and 
usually respond quickly to treatment. An especially disagree- 
able feature is their tendency to recur. This doubtless is due to 
the existence of some abnormal condition of the naso-pharynx, 
pharynx, or tubes. The various forms of rhinitis, hypertro- 
phied pharyngeal and faucial tonsils, and pharyngitis must be 
thoroughly cared for until a healthy condition returns. If spon- 
taneous rupture occurs without much delay, or if paracentesis is 
done promptly, the dangers are lessened. Extensions of the 
purulent process are always alarming. 



CHAPTER XXV 

DISEASES OF THE SKIN 

Scleroderma 

This unusual condition consists of a hardening of the skin, with 
subsequent atrophy and malnutrition. Its cause is unknown, and 
there are no characteristic lesions with which we are acquainted, 
excepting an increase in the connective tissue elements and the 
natural results of such a change. The disease may begin at any 
time of life after infancy, and may involve a part or the whole 
of the body. The face, neck, and trunk are oftener attacked than 
the extremities. The process may or may not begin with oedema ; 
the affected area then becomes indurated, the skin cannot be 
picked up, and does not pit on pressure. The color may be 
pale and lifeless, and later on it may be sufficiently pigmented 
to assume a much darker hue. On account of the hardening, the 
muscles of the face and body become rigid, so that there is a pro- 
gressive loss of expression and motion. Superficial sensation 
becomes diminished, but tenderness is increased. The skin and 
mucous membranes finally become so tense and rigid that circula- 
tion is impeded and muscular atrophy results ; this tenseness may 
be so much exaggerated that deformities are very apt to ensue. 
The evil effects may not only be rendered greater, but also may 
be hastened by disease of the heart, lungs, and gastro-intestinal 
track. When death occurs its immediate cause is marasmus. 

There is no specific treatment ; and all one's efforts are 
directed toward the maintenance of body-heat, the vigorous use 
of massage and inunctions of oil, the careful regulation of the 
patient's general circumstances, and the administration of tonics. 

Seborrhcea 

When a child comes into the world he is covered by an oily 
secretion, the so-called vernix caseosa. This may be called a 

621 



622 THE MEDICAL DISEASES OF CHILDHOOD 

physiological seborrhcea. When the child is weak or suffers from 
ansemic, nutritional, or gastro-intestinal disorders, or is poorly 
cared for, a functional disease of the sebaceous glands may 
result, which is called by the same name. It consists of oily or 
scaly crusts upon the surface. These crusts are made of fat 
and free oil-globules, epithelial debris, and amorphous granular 
matter. It may affect any part of the surface excepting the 
palms and soles, but its most common locations are on the scalp, 
and in badly nourished children on limbs and body. It is like- 
wise often seen in smaller degree at the umbilicus, under the 
prepuce of the penis, and about the clitoris and labia. In most 
cases the condition is not serious, nor does it involve organic 
changes in the scalp, skin, and mucous membranes ; if, however, 
it is allowed to lie undisturbed for too long a time, an eczema 
may develop from it. It produces no itching nor infiltration of 
the skin. 

To remove it one should soak the crusts with olive oil until 
they fall off; under no circumstances should they be roughly 
pulled off with the fingers or a fine comb. The parts should then 
be covered with vaseline, or a one per cent ointment of salicylic 
acid. Seborrhcea of the umbilicus or genital organs requires 
thorough washing with soap and water, which may be followed 
by the application of a solution of alum. 

Hypekidrosis 

When the sweat-glands are in a condition of over-activity, an 
excessive amount of perspiration may be secreted, caused by some 
functional disorder of the sympathetic nervous system. In some 
cases this is hereditary or congenital. Under such circumstances 
it is usually located on one part of the body, such as the hands or 
feet, or any part of them. With sweating of the feet, sometimes 
called bromidrosis, the odor may be very offensive. In other 
cases the sweating may be confined to the head or forehead, as in 
malnutrition and rickets. In still others it may cover the whole 
body and then is merely a temporary symptom, as in rickets, the 
acute fevers, and tuberculosis ; in still other instances it may 
result from overheated rooms and the wearing of clothes that are 
too warm. Thus it may be acute, subacute, or chronic. 

The treatment varies according to circumstances. In the 



DISEASES OF THE SKIX 623 

acute fevers nothing is needed beyond a liberal number of baths. 
In malnutrition and rickets, the sweating disappears as soon as 
the original disease is eliminated. In congenital or hereditary 
sweating of the feet and hands the treatment is more serious and 
less successful. Washing the parts two or three times a day 
with a mixture of water and alcohol, in which is dissolved one per 
cent of salicylic acid, is sometimes useful. Or a dusting powder 
consisting of one per cent salicylic acid with boracic acid and oxide 
of zinc will often give good results. The treatment must often 
be continued for months. If this powder is used for the feet, it 
may be sprinkled in the stockings ; if the hands are affected, the 
patient must as continuously as possible wear gloves into which 
the powder is put. At the same time the general physical con- 
dition may need the regulation of the diet, exercise, and the 
continued use of tonics. 

Erythema 

Erythema is a hyperaamic condition of the skin in which the 
influenced area may be circumscribed or diffuse ; it is always flat, 
and its heightened color fades on pressure. Usually there are 
few subjective symptoms, such as itching, burning, and tingling. 
The simple erythema, according to its cause, is divided into E. ca- 
loricum or the erythema of heat and cold ; E. traumaticum from 
mild injuries such as pressure or friction; E. venenatum, due to 
poisons ; E. intertrigo, produced in fat children where two skin 
surfaces meet and rub, as in the groin ; E. pernio, commonly called 
chilblain. E. intertrigo is very common, is heightened in likeli- 
hood and severity by malnutrition, and is exaggerated by lack of 
cleanliness. Chilblains occur for the most on terminal parts of 
the body, such as fingers, toes, nose, and ears, especially in poorly 
nourished and anaemic children. For the sake of completeness 
one may mention the so-called symptomatic erythema that occurs 
as the specific eruption in the acute infectious diseases, such as 
scarlet fever, measles, rotheln. The form called infantile ery- 
thema is of very frequent occurrence in }^oung children who are 
suffering from gastro-intestinal irritations. The treatment of all 
these conditions consists of the emptying and regulation of the 
gastro-intestinal track and the application of a bland dusting 
powder. In chilblains the inflamed skin may be painted with 
iodine and then protected. Most children suffering from erythema 



624 THE MEDICAL DISEASES OF CHILDHOOD 

may be suspected of some degree of atonicity, and must be treated 
accordingly. 

Erythema multiforme is usually described as an acute exuda- 
tive inflammation of the skin, characterized by the separate or 
combined appearance of erythematous, vesicular, papular, nodose, 
tubercular, and bullous eruptions. The names are descriptive of 
the appearances, but do not characterize the nature of the lesion. 
In the same way we get the name E. annulare from an erythe- 
matous patch which has faded in the centre; E. gyratum when 
such rings meet and produce a broken figure ; E. marginatum 
denotes the occurrence of separated patches with sharp edges. 
Tubercles, vesicles, and bullae occurring in an erythematous erup- 
tion give an adjectival appellation to the disorder. The aetiol- 
ogy of these various forms is conjectured — not known. It has 
been commonly supposed that they are angio-neurotic in their 
nature, and that some septic condition in the body gives rise to 
them. An especial form, E. nodosum, whose name describes its 
appearance, is a frequent accompaniment of rheumatism. In 
this case, also, the manner of causation is unknown. These 
various varieties are apt to occur in connection with systemic 
disorder, such as fever and malaise with a local accompaniment of 
itching, burning, and a variable degree of tenderness. 

The treatment is general and symptomatic. In most cases 
the erythema exists in connection with some general pathological 
condition, either trivial or serious. Free catharsis is always use- 
ful, combined with a strict regulation of the gastro-intestinal sys- 
tem. Bland dusting powders or ointments will relieve the local 
irritation. In all such cases the eruption should not be regarded 
as a distinct entity, but rather as the expression of disturbed 
nutritional equilibrium. 

Miliaria 

Prickly heat, otherwise known as miliaria and lichen tropicus, 
is an acute irritation or inflammation of the sweat-glands, the 
outward expression of which is a vesicular or papular eruption; 
under proper conditions of irritation and infection the papules 
and vesicles may become pustules. The main serological factor 
seems to be a combination of unusual heat and a condition of debil- 
ity. Two varieties are described : one is inflammatory and is rep- 
resented by two types, M. rubra, or vesiculose ("red gum"), and 



DISEASES OF THE SKINT 625 

M. papulosa (" prickly heat ") ; the other is non-inflammatory, and 
is called M. crystallina, or sudamina. In miliaria the changes con- 
sist in a congestion of the capillary vessels about the ducts with 
resulting effusion about and into the sweat-glands, to which is 
added a variable but always excessive amount of normal excre- 
tion. In sudamina an excess of secretion is dammed up in the 
deep strata of the horny layer, on account of which the duct 
becomes filled. The result is a destruction of the wall, followed 
by the development of a small, white vesicle. 

Besides the eruption, there is a keen sensation of itching, 
burning, and tingling. The rash may be scattered all over the 
body, but the face and extremities are oftener attacked than the 
trunk. The vesicles are set close together, are not large, and 
unless infected have no discharge. 

The simplest treatment is usually the best. The bowels should 
be thoroughly cleansed, the diet should be very plain and light, 
and considerable water should be given to drink. The child may 
be bathed once or twice a day, preferably in alkaline water, and 
powdered after the bath with a simple dusting powder, such as 
talcum powder or a combination of oxide of zinc and starch. If 
the child is badly nourished, he may need tonic treatment before 
the eruption will be permanently cured. 

Eczema 

Eczema is the most important, and, potentially, is the com- 
monest skin disease of infancy and childhood. Its forms are 
numerous, not merely because there are many distinct varieties, 
but rather because there are many degrees of severity complicated 
by different intensities of adventitious infection. It should pri- 
marily be regarded as a catarrhal inflammation of the skin with 
manifold developmental changes. 

Causes. — In children the skin is very sensitive, and its 
relation to the gastro-mtestinal and excretory systems is very 
intimate, so that disorders . of them are yery apt to engender 
simultaneous or consequent irritations of the surface. We see 
this especially well demonstrated in children who have by inheri- 
tance a sensitive skin, as well as in those who are weak, poorly 
nourished, and poorly cared for. After exhausting disease and 
the acute infectious fevers, such disorders are matters of common 
2s 



626 THE MEDICAL DISEASES OF CHILDHOOD 

complaint, most of all when there are disorders of the gastro- 
intestinal track. Indeed, this last factor may in many ways be 
regarded as the main source of eczema in its various forms. The 
more serious and prolonged the digestive disorder, the greater 
is the likelihood of an eczematous outbreak. Even where the 
former seems not especially serious, as in chronic constipation or 
the sub-acute or chronic enteritis which runs through a tiresome 
series of remissions and exacerbations, the danger to the skin is 
definite and pronounced. As one would naturally expect, arti- 
ficially fed children and those older ones whose diet is poorly 
arranged are more frequently attacked than the breast-fed and 
wisely nourished. Certain foods, such as oatmeal and potatoes, 
are commonly blamed as being causative of this disease, but the 
charge is not entirely logical. We should go farther back and 
ascertain whether the children in question were really receiving 
in their food too great a proportion of these articles, and whether 
other and similarly one-sided dietaries could not produce the 
same tendency to general and gastro-intestinal inefficiency, and, 
therefore, to this skin disease. 

In addition, almost any irritating and injurious influence from 
without, especially when the victims are not strong and well 
nourished, may start the inflammation. Thus scratches, wounds, 
excessive heat and cold, harsh winds, bad soaps and water, lack 
of cleanliness, dirty or coarse clothing, may be the starting-point. 
The milder and non-inflammatory dermal disorders frequently 
develop into an eczema. And when the exposed rete becomes 
infected with septic micro-organisms, the severer forms of the 
disease may be expected. 

Lesions. — The changes resemble those which are so commonly 
seen in the mucous membranes. The upper layers of the epithe- 
lium become degenerated, leaving the rete exposed and unpro- 
tected. The vessels are congested, and there may be an exudation 
of serum and fibrin, in which are mixed some white blood-cells, 
pus-cells, epithelial debris, and micrococci. Infiltration may exist 
to a variable extent, and the formation of scales and crusts is rea- 
sonable and easily understood. Thus the surface may be dry or 
wet, fairly clear, or covered with foul crusts ; and hardness, stiff- 
ness, and fissured and roughened conditions follow mechanically. 

Symptoms. — The commonest variety of eczema is the ordinary 
chronic form or eczema rubrum. Its usual location is any part of 



DISEASES OF THE SKIN 627 

the head or face, but it may extend all over the body. The first 
signs, as a rule, are small scattered papules which break down and 
expose a raw, moist surface. These areas spread and meet, their 
exudate thickens and hardens, and the whole surface itches and 
burns to a most irritating degree. Usually the child scratches it, 
and thus causes some bleeding. The skin becomes swollen, hard, 
thickened, and irregular. With it is associated hyperplasia of 
the lymph nodes, which may finally break down and suppurate. 
Both dermal and adenitic disorders may spread to an indefinite 
degree. 

Seborrhoeic eczema is really a combination of a seborrhcea and 
areas of eczema, caused according to Unna by a certain " mulberry 
coccus." It usually begins on the scalp and face, from which it 
spreads to the neck, chest, back, and parts where the skin is 
tender. The condition of the head is seborrhoeic, that of the body 
is seborrhoeic and eczematous. There is less infiltration in the 
skin, less true inflammation, and less pain. 

Intertrigo, frequently classified as eczematous, is really so in 
a potential sense only. It is caused by uncleanliness, by wearing 
unclean napkins, by the influence of two moist surfaces upon 
each other when they are in contact. It is most commonly seen 
about the buttocks, genitals, and anus, but often it attacks the 
groin, the axilke, the neck, and behind the ears. At first there is 
a reddened patch of skin which may pass away or become exag- 
gerated. In the latter case the upper layers of the epithelium are 
thrown off, the rete becomes exposed, and the beginning of an 
eczema exists. In this disorder the formation of thick crusts 
need not be expected, but the itching, tenderness, and pain are 
present. 

As has been said above, an eczematous surface ma} r become 
infected with septic micro-organisms, in which case a pyogenic 
process may naturally result. The most favorable conditions for 
the propagation of such a process exist in the hairy scalp, and 
there one finds the so-called pustular form. The crusts grow in 
and through the mass of hair, so that ideal conditions for pus- 
formation exist. Either a part or the whole scalp may be cov- 
ered, for the spread of the disease is rapid. Contagion is likewise 
easy, or a series of auto-infections may prolong the disease for 
weeks. The lymph-nodes are enlarged and tender, and may 
finally suppurate. 



628 THE MEDICAL DISEASES OF CHILDHOOD 

Treatment. — As in every other disease where there is an 
ascertainable cause, the first and most important step is to recog- 
nize and remove it. In many cases this alone is enough to bring 
about a cure. Especially it is necessary to regulate the condi- 
tion of the gastro-intestinal track and the kidneys. An equally 
important factor is the diet, from which every component part that 
is at all irritating or difficult of digestion must be removed. Chil- 
dren who are being fed artificially must have their milk sufficiently 
modified and diluted to secure its easy and satisfactory absorption. 
The details of such modification may be referred to in the section 
on Feeding. The diet of older children should be largely nitroge- 
nous. When the disease is acute, the food should be made up of 
milk and soup, which, as the patient improves, may be supple- 
mented by eggs, dark meat, toast, and finally fresh vegetables and 
fruit. The details of exercise and ventilation should be rigidly 
administered. While the healthy skin should be carefully washed 
in the usual manner, the eczematous areas should first be freed from 
crusts and scales by means of olive oil or sweet oil, and then may 
be cleansed with bran water or starch water. 

The medicinal treatment need not be complicated. Disorders 
of the gastro-intestinal track and the kidneys should be cared for 
according to their indications until their action is fully and 
efficiently restored. As soon as possible, tonic treatment should 
be begun. The affected surface may at the beginning be so sensi- 
tive and the itching so disturbing that one may need a carbolic 
wash, usually a one per cent or one and a half per cent solu- 
tion, to give relief. Where there are exudation and crusts a 
simple salve made of bismuth subgallate and rose water oint- 
ment, eight to sixty, will give good service. With this and 
all other salves the rule should be made to remove the mixture 
daily by means of sweet or olive oil, to wash the surface as 
mentioned above, and then apply a fresh quantity of the oint- 
ment. In the sub-acute or chronic cases an ordinary zinc and 
tar ointment may be prescribed. Where there is little or no 
crust formation Lassar's paste is in most cases efficient ; and in 
the eczematous intertrigo no more than a good dusting powder 
is required. In the pustular form nothing curative can be 
expected until the crusts have been entirely removed and the hair 
clipped close ; the surface should then be washed with a weak 
carbolic solution, and covered with Lassar's paste or a resorcin 



DISEASES OF THE SKIN 629 

mixture. The annoying eczema of the ears generally improves if 
pieces of gauze soaked in zinc and calamine lotion are placed on it 
and between the ear and the opposing surface of the head. In all 
cases, however, the external treatment must not be regarded as 
the most important factor in the cure. The internal care comes 
first, and by a long interval at that. 

Prognosis. — The general outlook is thoroughly good. Cases 
which persist in a discouraging series of remissions and exacerba- 
tions are usually those in which the diet is poorly arranged, and 
the alimentary and excretory functions are in debilitated condi- 
tion. This applies to a large proportion of the so-called chronic 
and incurable cases. 

Simple Herpes 

Herpes simplex, called fever blisters and cold sores, is a mild, 
inflammatory disorder that appears on any part of the face below 
the forehead, usually on the upper lip, and sometimes on the 
mucous membranes. It is caused by febrile conditions, exposure, 
and irritation. It consists of one or more vesicles with a reddened 
base. At first they are clear, later they are cloudy and contain a 
small quantity of pus, and finally they heal under a crust forma- 
tion which scales off, leaving a faintly reddened surface. In a 
week or ten days the skin appears normal. 

The stomach and intestines should be emptied and any prece- 
dent febrile condition must receive its appropriate care. The 
vesicles may be protected by a layer of Lassar's paste or flexible 
collodion. 

Heppes Zostep 

This disease, also called shingles, is a descending interstitial 
neuritis of the spinal ganglion ; it may likewise originate from a 
cerebral or peripheral source. Its cause is unknown, and some 
observers believe that it should be classified among the acute 
infectious diseases. It consists of a group of vesicles with a 
surrounding reddened zone, and its location lies along the course 
of the cutaneous nerves. While it is oftenest seen on the body, 
it may likewise occur on the face, head, or neck. The vesicles are 
light colored and filled with a clear serum, which after the lapse 
of a feAv days becomes puriform. After running a course of from 
one to three weeks, the vesicles desiccate, a brown crust falls off, 



630 THE MEDICAL DISEASES OE CHILDHOOD 

and the delicate reddened skin is seen to be almost normal. 
These vesicles may coalesce and form blebs of considerable size, 
but their separate structure can nevertheless be recognized. Very 
rarely they are hemorrhagic. At the beginning of the eruption 
there may be pain, malaise, and a rise of temperature, which in a 
short time, as a rule, pass away. 

The treatment, outside of free catharsis and regulation of the 
diet, calls for no more than protection of the vesicles. So long 
as they are not irritated or ruptured, no destruction of the skin 
need be feared. Ordinary dusting powder covered with absorbent 
cotton, which is held in place by a roller bandage, gives sufficient 
relief. On the face a convenient dressing is flexible collodion. 
In children the pain is so slight as rarely to call for sedatives. 

Impetigo Contagiosa 

Impetigo contagiosa is an acute contagious disease, oftenest 
seen in dirty children during warm weather. There are practically 
no symptoms except the eruption which in most cases begins on 
the face, neck, and hands, whence it may spread to the body 
by auto-infection. It appears as a series of small vesicles, each of 
which is surrounded by a reddened zone. These vesicles grow 
until they may be as large as one's finger nail, or even larger. At 
first they are tilled with a clear serum which gradually becomes 
purulent. Simultaneously the vesicles become umbilicated, and 
finally they rupture. The crusts then drop off and the skin 
returns to its normal condition. The disease lasts from one and 
a half to three weeks, unless auto-infection takes place. 

For treatment one should remove the crusts and apply a 
mild, antiseptic salve, such as Lassar's paste. 

Dermatitis Exfoliativa Neonatorum 

A severe form of exfoliative dermatitis occurs in children 
under a month of age. Its origin has been the subject of much 
conjecture, and is not certainly known. The only known lesion 
as well as symptom is a dermatitis that begins about the mouth, 
whence it spreads to the rest of the body. Fluid may collect 
under the epidermis, which flakes off and leaves a raw surface. 
The eruption develops in various ways and may resemble various 
other skin diseases, and also may be followed by eczema, furun- 



DISEASES OF THE SKIN 631 

cles, or superficial gangrene. The treatment is symptomatic, and 
in about fifty per cent of the cases is unable to prevent death. 
The disorder was first described by Ritter, after whom it is some- 
times called. 

Dermatitis Gangrenosa Infantum 

As a result of marked debility superficial gangrene may occur 
in weak children. Usually it attacks marantic, syphilitic, or 
tuberculous babies, or those who have gone through an acute 
and exhausting sickness. Rarely it may follow a septic infection. 
The eruption occurs as a superficial slough, or a pustular process 
that becomes gangrenous. With these lesions there are the 
symptoms of debility, high and variable temperature, and severe 
systemic depression. The treatment consists of local antiseptics 
and the administration of tonics. 

The prognosis is not good. 

Urticaria 

This disorder, commonly called hives or nettle-rash, is a com- 
mon and transitory eruption, which in most cases follows disturbed 
gastro-intestinal function. It may be caused by eating strawber- 
ries, pastry, and meats that are hard to digest. It occurs in 
malaria, and as the result of taking certain drugs, notably quinine. 
It consists of wheals or streaks which vary in size from a seed to 
one's finger nail. These pomphi are slightly elevated, white in 
the centre, and pink at the periphery. There is a coincident itch- 
ing and tingling, which may pass away within one or more hours, 
followed in a short time by the subsidence of the swelling. The 
eruption sometimes is papular, and the effusion remains for a vari- 
able time after all other symptoms have passed away. Any part 
of the face and body may be affected. On account of the intense 
itching, the child is apt to scratch the parts with enough vigor to 
produce excoriations and superficial infections. The course of 
the disease is generally very short, excepting in the papular form, 
which may persist for weeks. 

The treatment is mainly directed to the care of the alimentary 
system. The bowels should be thoroughly emptied, the diet 
should be made very simple and light, and a generous amount of 
drinking water should be ordered. Functional disorders of the 



632 THE MEDICAL DISEASES OF CHILDHOOD 

stomach and intestines must be carefully followed up, under pen- 
alty of a recurrence of the rash. For the eruption little need be 
done. Warm alkaline baths are grateful to the patient, and the 
good effects may be prolonged by sponging the affected areas with 
a one and a half per cent or two per cent carbolic solution. If 
the wheals are so situated that the clothing rubs against them, 
they should be sprinkled with a dusting powder, and covered 
with cotton and a roller bandage. 

FiXRUNCULOSIS 

A furuncle, commonly called a boil, is a local inflammation 
about a hair follicle or gland of the skin which follows infection 
by staphylococcus aureus. In most cases there is an antecedent 
condition of debility. The affected spot at first tingles and feels 
uncomfortable, then a small, highly colored papule forms which 
gives way to a hard, dull-red pyogenic process, in the centre of 
which is the so-called core. If left alone pus forms, and may 
then escape by spontaneous rupture of the skin, although occasion- 
ally the process aborts and is followed by absorption. The fu- 
runcles may be located in any part of the body, but usually affect 
the face, neck, and back ; they may occur singly or in large 
numbers, in one or several crops. 

As soon as the furuncle is forming, the hair in the centre of 
the follicle, if it can be seen, should be pulled out. A moist dress- 
ing, composed of gauze moistened with bichloride of mercury 
solution (1-2000) and covered with rubber tissue, should be held 
in place over the inflamed area by a roller bandage. If the pro- 
cess does not then stop, the furuncle must be freely incised and 
packed. The boil may often at the beginning be aborted by 
touching its centre with a sharpened tooth-pick, dipped in pure 
carbolic acid. Various salves and plasters have been recommended 
at various times, but their action is not reliable. I have obtained 
most satisfaction from ordinary surgical methods. 

Lentigo 

Lentigo, or freckles, is a localized pigmentation deposited in 
the rete. It occurs in older children, most profusely in those of 
a light complexion, and is usually, but not exclusively, situated 
on the face and hands. Exposure to the sun seems to be the 



DISEASES OF THE SKIN 633 

cause. They are hard to remove, and recur easily and repeatedly. 
In most cases it is best to leave them undisturbed ; but if there 
is any good reason why they should be eliminated, an ointment 
of equal parts of ammoniated mercury and bismuth subgallate 
plus ten times as much rose-water ointment may be prescribed. 

Ichthyosis 

Ichthyosis is a foetal, congenital, or infantile disease in which 
the skin is dry, scaly, and horny. The cause of it is unknown ; 
nor is the fact that the condition improves in warm and becomes 
worse in cold weather susceptible of exact explanation. It may 
be on a localized area, usually an extensor surface, or may cover 
the whole body. The condition may vary from a mere dryness 
and tendency to desquamation, to the formation of large, thick 
scales, which occasionally are diamond-shaped. A variety, called 
ichthyosis hystril, consists of an exaggeration of this appearance, 
so that the skin may be very rough, or have small spines. 

The hair and nails are dry and brittle, the skin cracks easily, 
and the margins of the orifices are distorted. The epithelium 
shrivels off in small or large flakes, and the tender tissue under- 
neath gradually grows hard, contracted, and deformed. 

There is no treatment except warm baths and continued 
inunctions with lanolin. At the same time the general health 
must be promoted in all possible ways. 

If the condition appears at birth, the prognosis is bad. If it 
comes on in infancy or childhood, it may yield in part to treat- 
ment, but does not entirely disappear. In older children it seems 
to have no deleterious influence upon vitality or life. 

Verruca 

Verruca is the common excrescence called warts, which usually 
occurs on children's hands. Other locations, such as the head, 
body, and extremities, are possible, but much less frequent. It may 
be congenital or acquired, and in a few cases seems contagious. 
Its cause is unknown. The growth consists of a hypertrophy of 
the papillse, as large as the seed of an orange, and covered with a 
thickened epidermis. Its surface may be smooth or rough, or 
divided complexly, as if made up of several factors. The main 



634 THE MEDICAL DISEASES OF CHILDHOOD 

interest in it lies in the method of easy and painless removal. 
For this one may use an alcoholic saturated solution of salicylic 
acid, or a mixture of this acid and collodion in the proportion of 
one to fifteen. The first may be used twice a day, the second 
only every two days. 

N^YUS PlGMENTOSUS 

Naevus pigmentosus, or mole, is a localized hyperpigmentation 
in the rete of the skin, with or without an increase of the connec- 
tive tissue. It may be congenital, or acquired at any period of 
life ; its cause in either case is unknown. It may be as small as 
a pin's head and as large as a lima bean, its color may vary from 
a light to a dark brown or black, and its surface may be smooth 
(N. spilus), warty (N. verrucosus), or covered with hair (N. 
pilosus). While in children it is usually harmless, it may, in 
older persons, be the seat of a malignant growth. Removal in 
children is usually harmless, although I saw one case in which 
sarcoma developed in the scar within seven months after opera- 
tion. If removal is desired, nothing more than the ordinary 
surgical measures is needed. 

Alopecia Areata 

This condition is doubtless trophoneurotic, but there is no 
fixed certainty in the opinion. It has been attributed to para- 
sites, to malnutrition, to neuralgia, to trauma, and the debility 
that follows acute disease. Any portion of the scalp may be 
affected, with or without the symptom of pain. As a rule, the 
disease begins with a sudden falling of the hair in a fairly circu- 
lar area, the size of which may be large or small ; or more than 
one area may exist, and when they coalesce — as they sometimes 
do — a large part of the hairy surface may be involved. The 
bald spots are white, shining, and slightly depressed. After a 
time, varying from months to years, the hair returns, at first thin 
and white, later full and of normal color. 

No special treatment is needed besides attention to the gen- 
eral health, and friction with a stimulating lotion, such as alcohol 
or a weak solution of the tincture of cantharides ; other useful 
remedies are the tincture of green soap and bichloride of mercury. 



DISEASES OF THE SKIN 635 

Ringworm 

Ringworm is a parasitic disease caused by trichophyton, a fun- 
gus which may grow in the skin, hair, and nails. When it occurs 
on the skin it is called tinea circinata, and on the scalp tinea ton- 
surans. In most cases the disease can be recognized at a glance. 
On the body the favorite locations are the face, neck, and hands. 
It begins as a small, pink, and elevated spot that grows larger 
at the margin while the centre heals. The rings seldom become 
larger than a watch glass, and may then remain stationary, and 
finally disappear. In some cases there may be several adjacent 
patches which spread until they meet. At the points of junction 
the outline is broken ; in others the centre refuses to heal ; in 
still others the periphery may be sufficiently irritated to produce 
a crop of papules or vesicles. 

Ringworm of the scalp is somewhat frequent, and on account of 
its contagiousness spreads very rapidly from one child to another. 
Like the disease on the body, it may appear on one or several 
areas. They are fairly circular, and are studded with short and 
broken hairs. The capillary destruction may be so complete that 
not a hair is left, and the skin is left as smooth as in alopecia 
areata. In some severe cases pyogenic infection may take place 
around the hairs, with a consequent pus-formation in and under 
the follicles. Usually the disease is readily recognized by the 
combination of the round patch in which are a few ragged hairs, 
the scales on the skin, and the lustreless hairs in the periphery. 
The diagnosis may be confirmed by microscopical examination, 
which shows the spores in the hairs and the mycelium in the 
scales. There are no subjective symptoms. 

The preventive treatment is exceedingly important. If con- 
venient, the child may be isolated ; in all cases he should be taken 
from school, should not be allowed to sleep with other children, 
and until the disease is cured should wear a close-fitting cap 
which will not permit a spread of the disease. As soon as the 
ringworm is discovered, a wide zone around it should be cleared 
of hair, and the diseased hairs should be pulled out. Germicides, 
in as strong a mixture as the skin will bear, should be continu- 
ously kept on the affected area. Tincture of iodine was formerly 
used for this purpose, as also was kerosene oil. The practice 
nowadays is to use bichloride of mercury dissolved and mixed 



636 THE MEDICAL DISEASES OF CHILDHOOD 

in lanoline and olive oil in the proportion of one to five hundred. 
A further method consists of the continued use of moist dressings, 
composed of gauze saturated with a solution of bichloride of mer- 
cury and covered with rubber protective. Toward the end of 
the disease these dressings may be replaced by ointments of 
salicylic acid. 

Favus (Tinea Favosa) 

This is a parasitic disease which gets its name from the re- 
semblance that its characteristic crusts or scutula bear to a honey- 
comb. The responsible parasite may occur in five species of 
achorion: A. Schonleini, A. atakton (Unna), A. enthytrix, and 
the two unnamed species of Bodin. The usual microscopical 
picture is a mass of small, jointed mycelia, growing approximately 
at right angles with the horny layers of the epidermis (Unna), 
and associated with many conidia. The disease appears for the 
most part in dirty children, who become infected from other 
children, or from the domestic animals. 

Generally the scalp is first infected, but the skin surface of the 
body and even the nails ma}^ be attacked. The first sign of the 
invasion is the appearance of a small, yellow crust- or scutulum 
about a hair. Many areas may gradually become covered, and 
finally the crusts may coalesce, thus forming a large scaly surface. 
These crusts give of! a peculiar mouse-like odor that is quite 
characteristic of the disease. If a dry scutulum is pulled off, a 
smooth, dull, and slightly irregular surface is seen. But if these 
crusts are allowed to remain so long that they dry up and fall off 
spontaneously, a dry, weak looking, scar-like area remains. The 
hairs which are caught in the crusts become starved, dry, brittle, 
and finally fall out. Favus is commonly associated with pedicu- 
losis, and the combination of the two produces much itching. 

On the skin surface the attack begins with the formation of a 
small pimple, surrounded by a red and inflamed zone. Within 
this the crust begins to form. If the disease attacks the nails 
they become dry, harsh, irregular, and easily friable. Scutula 
may form on them, and if the process is not stopped the whole 
nail may be lost. 

In addition to the local symptoms, the general condition of the 
child is usually poor. 



DISEASES OF THE SKIN 637 

The first step in treatment is to soak the crusts for a day with 
sweet oil, after which they must be removed, and the entire area 
must be epilated. Germicidal ointments or moist dressings (bi- 
chloride of mercury), should then be applied, and their use should 
be continued until the disease has quite disappeared. If this 
treatment is begun promptly, the disease may be checked and the 
parts restored to their normal condition. But if the crusts have 
been allowed to remain for weeks, a new growth of hair need not 
be expected. Under such circumstances, healthy, new-plucked 
hairs have been implanted with a fair amount of success. A 
recent treatment consists in the use of moist bichloride of mercury 
dressings under a coil of Leiter's tubes, through which a stream 
of hot water (52-53° C.) flows. 

Favus is very tenacious, and demands long and patient treat- 
ment before it is eradicated. All crusts and dressings should be 
burned as soon as removed, in order to prevent further contagion. 
The differential diagnosis is made by the mouse-like odor, the 
yellow crusts and the microscopic appearance. 

Scabies 

Scabies is a parasitic disease caused by the burrowing into the 
skin of the female acarus or itch mite. The male remains on the 
surface, and has no active part in the disease. The localities most 
frequently affected are those where the epithelium is tenderest, 
and where the mite has least difficulty in making a burrow for 
her eggs. This burrow is most readily seen between the fingers, 
in the armpits, about the genitals, and in the soft flexures of the 
joints. They may be recognized as short, black, irregular lines 
which lie near the surface epithelium. As a result of their pres- 
ence, the skin may be sufficiently inflamed to be studded with 
vesicles, papules, and pustules. These are exaggerated by the 
vigorous scratching which the child is forced to make, most of all 
on the portions of the skin which are kept moist and warm. 
The blood-marked scratches are often the first sign that attracts 
the observer's attention. 

The active treatment must be supplemented by preventive 
care. The clothing which the child has been wearing should be 
thoroughly boiled or destroyed. The patient should be given a 
warm bath of a quarter to a half hour in duration, and then should 



638 THE MEDICAL DISEASES OF CHILDHOOD 

be scrubbed with a mixture of equal parts of green soap and blue 
ointment in the same manner that one would use soft soap. After 
being taken from the bath and dried, his body should be anointed 
with pure balsam of Peru. The bedding should be thoroughly 
cleansed, and he should not be allowed to sleep with other 
children until he is cured. A few nights of this treatment are 
sufficient to bring about thorough cleanliness. 

Pediculosis 

Contamination of the hair with pediculi capitis is so common 
that it scarcely needs description. One may be justified in men- 
tioning that the irritation which they bring about, added to the 
scratching and infection produced by the child's finger nails, is 
often sufficient to set up a dermatitis, crust formation, or even a 
pustular eczema. Examination will show the lice on the head 
and the nits on the sides of the hairs. When the irritation of the 
scalp is severe, there will be an enlargement of the cervical glands. 

Rarely the child's eyebrows and lashes may be infected by the 
pubic louse. In this case, besides the louse and nits, there may 
be minute hemorrhages in the near-by tissue. 

To cleanse the child the hair should be cut, the crusts, if any, 
removed, and the scalp should be thoroughly scrubbed with a 
mixture of green soap and blue ointment, in the same way that 
one would use soft soap. One or two applications are efficient. 



INDEX 



Abdomen, palpation of, 32. 

Abscess of the brain, 566 ; causes, 566 ; 
differential diagnosis, 567 ; lesions, 
566 ; symptoms, 567 ; treatment, 
567. 

Abscess, peritonsillar, 241 ; prognosis, 
242 ; treatment, 242. 

Abscess, rectal, 199. 

Abscess, retro-pharyngeal, 246-247. 

Abscess, subphrenic, 148. 

Accoucheur's hand, 602. 

Acetone, 34. 

Achondroplasia, 214. 

Acid, diacetic, 34. 

Acute arthritis of infants, 616. 

Acute ascending paralysis, 561. 

Acute pyogenic infection, 62 ; symp- 
toms, 63 ; treatment, 63. 

Adenitis, lymph-, retro-cesophageal, 115. 

Adenitis, lymph-, retro-pharyngeal, 246. 

Adenoid vegetations of pharyngeal vault, 
234. 

Adventitious sucking, 590. 

Alalia, 588. 

Albuminuria, functional, 34. 

Alcohol, use of, 37. 

Alopecia areata, 634. 

Amaurotic family idiocy, 582 ; lesions, 
582 ; treatment, 582. 

Amazia, 50. 

Amoebic infection, ileo-colitis due to, 
164. 

Amyelia, 39. 

Amyloid degeneration of kidney, 381. 

An semia, infantile pseudo-leucsemic, 337 ; 
differential diagnosis, 338 ; lesions, 
338 ; prognosis, 338 ; symptoms, 338 ; 
treatment, 345. 

Anaemia, pernicious, 334 ; differential 
diagnosis, 337 ; lesions, 335 ; progno- 
sis, 337 ; symptoms, 336 ; treatment, 
344. 

Anaemia, simple secondary, 329 ; symp- 
toms, 330 ; treatment, 344. 



Anaemic murmurs, 321. 

Analysis of infant foods, 91. 

Anencephalia, 38. 

Animal parasites of the intestines, 181 ; 
symptoms, 184, 185, 186 ; treatment, 
184, 185, 186, 187. 

Ankle, congenital dislocation of, 52. 

Annulus tympanicus, growth of, 9. 

Anterior poliomyelitis, acute, 549. 

Antipyretics, use of, 35. 

Antipyrine, use, 35-36. 

Anuria, 33; causes, 33 ; treatment, 33. 

Anus, fissure of, 201. 

Anus, prolapse of. 197. 

Aorta, congenital malformation of, 42. 

Aortic insufficiency in chronic endocar- 
ditis, 312. 

Aortic stenosis, in chronic endocarditis, 
313. 

Apex beat, location of, in infant, 13. 

Aphasia, functional, 587. 

Appendicitis, 191 ; causes, 192 ; differen- 
tial diagnosis, 196 ; lesions, 193 ; 
prognosis, ] 96 ; symptoms, 194 ; treat- 
ment, 195. 

Arrhythmia, 301. 

Arthritis in scarlet fever, 401. 

Arthritis of infants, acute, 616. 

Arthritis, rheumatoid, 615. 

Artificial respiration in asphyxia, 59. 

Ascarida, 184. 

Ascaris lumbricoides, 185 ; symptoms, 
185 ; treatment, 185. 

Ascaris mystax, 187. 

Ascaris vermicularis, 186. 

Ascites, 202. 

Ascites, chylous, 202. 

Asphyxia, 58 ; treatment, 59. 

Ass's milk, analysis of, 79. 

Asthma, 575 ; causes, 576 ; lesions, 577 ; 
prognosis, 578 ; symptoms, 577 ; treat- 
ment, 578. 

Ataxia, hereditary, 558. 

Ataxia, hereditary, cerebellar, 559. 



639 



640 



INDEX 



Ataxia, hereditary, spinal, 558. 
Atelectasis, 292 ; causes, 292 ; lesions, 

293 ; prognosis, 294 ; symptoms, 294 j 

treatment, 294. 
Atelomyelia, 39. 

Atrophy, acute yellow, of liver, 143. 
Atrophy, simple, 211. 
Auditory canal, in infancy, course of, 9. 
Auscultation, methods of, 31. 
Auscultation, of heart in children, 32 

Backwardness in acquiring speech, 588. 

Bacteriology of milk, 76. 

Balanitis, 357. 

Bauer's formulas for modifying milk, 38. 

Barlow's disease, 225. 

Bathing in infancy, 25. 

Beef extract, 96. 

Beef juice, 96. 

Belladonna, use of, 36. 

Bell's paralysis, 554. 

Bifid uvula, 102. 

Bilharzia hsematobia, 387. 

Biliary calculi, 149. 

Bladder, changes in position during 
growth, 19. 

Bladder, congenital deformities of, 48. 

Bladder, functional derangement of, 352. 

Blisters, use of, 37. 

Blood, diseases of the, 329. 

Boil, 632. 

Boiled milk, 86. 

Bone, comparative analysis of, 4. 

Bone-marrow in infant and adult, 4. 

Bothriocephalus latus, 183. 

Bottles, nursing, care of, 88. 

Brachycardia, 301. 

Brain, abscess of, 566. 

Brain, character of, in infants, 6. 

Brain, congenital malformation of, 38. 

Brain, cysts of, 569. 

Brain, development of, 6, 7. 

Brain, foetal, 6. 

Brain, glioma of, 569. 

Brain, hernia of, 38. 

Brain, myxo-glioma of, 569. 

Brain, sarcoma of, 569. 

Brain, tumor of, 568. 

Breathing, puerile, 31. 

Bromide of soda, use of, 36. 

Bronchi, diseases of, 255. 

Bronchiectasis, 277 ; causes, 278 ; le- 
sions, 278 ; symptoms, 278 j treat- 
ment, 279. 



Bronchitis, acute, 255 ; causes, 255 ; dif- 
ferential diagnosis, 261 ; lesions, 256 ; 
prognosis, 261 ; symptoms, 257 ; treat- 
ment, 259. 

Bronchitis, chronic, 262 ; lesions, 262 ; 
symptoms, 262 ; treatment, 263. 

Broncho-pneumonia, acute, 263 ; causes, 
263-264 ; differential diagnosis, 271- 
272 ; lesions, 265 ; prognosis, 271 ; 
symptoms, 267 ; treatment, 270. 

Broncho-pneumonia, chronic, 272 ; 
causes, 272 ; differential diagnosis, 
274 ; lesions, 272 ; prognosis, 274 ; 
symptoms, 273 ; treatment, 273. 

Broncho-pneumonia, special types of, 
266. 

Buhl's disease, Q6. 

Cajal's figures, 8. 

Calculi, biliary, 149. 

Calculi, renal, 388 ; symptoms, 388 ; 
treatment, 389. 

Calculi, vesical, 356. 

Cancer aquaticus, 103. 

Cancrum oris, 103. 

Caput succedaneum, 53. 

Cardiac disorders, functional, 301. 

Cardiac hypertrophy and dilatation, 318 ; 
prognosis, 321 ; symptoms, 319 ; treat- 
ment, 321. 

Care of premature infants, 91, 92. 

Cartilages, character of, in infants, 4. 

Cataleptic insanity, 586. 

Cavernous sinus, thrombosis of, 566. 

Cephalhsematoma, 53. 

Cephalhematoma, false, 54. 

Cephalhematoma, true, 53. 

Cephalocele, 38. 

Cerebral convolutions, development 
of, 6. 

Cerebral ganglion cells, development 
of, 6. 

Cerebral paralysis, infantile, 561. 

Cerebral paralysis, obstetric, 57. 

Cerebro-spinal meningitis, epidemic, 478. 

Cestoda, 181. 

Chapin's formulas for modifying milk, 
84, 85. 

Cheilitis, 101. 

Chicken-breast, 220. 

Chicken-pox, 415. 

Chilblains, 623. 

Child, the normal, 1. 

Chloral, use of, 36. 



IXDEX 



641 



Chlorosis, 331 ; causes, 332 ; differential 
diagnosis, 334 ; lesions, 332 ; progno- 
sis, 334 ; symptoms, 333 ; treatment, 
344. 

Chondro dystrophia, 214. 

Chorea, 598 ; causes, 598 ; differential 
diagnosis, 601 ; prognosis, 601 ; symp- 
toms, 599 ; treatment, 600. 

Chorea in connection with rheumatism, 
612. 

Chorea major, 604. 

Chorea minor, 598. 

Chorea of Sydenham, 598. 

Chromatin granules, 8. 

Chronic functional derangement of in- 
testines, 173 ; causes, 173 ; lesions, 
174 ; prognosis, 176 ; symptoms, 174 ; 
treatment, 175. 

Chvostek's symptom in tetany, 602, 
603. 

Chylous ascites, 202. 

Circulation, change from antenatal to 
postnatal, 13. 

Circulation, foetal, 12, 13. 

Clavicle, congenital dislocations of, 52. 

Clavicle, relative positions of, 12. 

Clavus, 604. 

Cleft palate, 44, 101-103. 

Cleft palate, effects of, 102. 

Cleft palate, time of operation for, 103. 

Clitoris, enlarged, 48. 

Clothing of infant, 25, 26. 

Club-hand, 52. 

Coccyx, development of, 9. 

Cold sore, 629. 

Colic, intestinal, in infants, 187. 

Colon, congenital malformations of, 46. 

Colon, growth of, 18. 

Colon, transverse portion, changes in 
position, 18. 

Colostrum, analysis of, 73. 

Compensation in heart disease, 311. 

Compression of spinal cord, 546 ; differ- 
ential diagnosis, 548 ; lesions, 546 ; 
prognosis, 548 ; symptoms, 547 ; treat- 
ment, 548. 

Conducting fibres of brain and cord, 7. 

Congenital atelectasis, 60 ; symptoms, 
61 ; treatment, 61. 

Congenital dislocations, 51-52. 

Congenital mucous polypus of umbili- 
cus, 67. 

Congenital rachitis, 222. 

Congenital subluxations, 52. 



Congestion of the kidneys, acute, 365 ; 
causes, 365 ; lesions, 365 ; symptoms, 
365 ; treatment, 365. 

Congestion of the kidneys, chronic, 372 ; 
causes, 372 ; lesions, 372 ; prognosis, 
374 ; symptoms, 373 ; treatment, 374. 

Congestion of liver, 138. 

Congestion of spleen, 149. 

Constipation, habitual, 188. 

Conus arteriosus, position of, in infants, 
13. 

Convulsions, 592 ; causes, 593 ; differen- 
tial diagnosis, 595 ; prognosis, 595 ; 
symptoms, 594 ; treatment, 594. 

Coprolalia, 588. 

Cord, compression of spinal, 548. 

Cord, spermatic, absence of, 51. 

Cord, treatment of, after birth, 24. 

Cord, tumors of spinal, 572. 

Corpora quadrigemina, medullation of, 7. 

Costal cartilages, position of, 12. 

Cows, breeds of, 79. 

Cow's milk, analysis of, 79. 

Cow's milk, modification, 80. 

Craig Colony, 597. 

Craniotabes in inherited syphilis, 517. 

Craniotabes in rachitis, 217. 

Cretinism, sporadic, 580. 

Crying, in abdominal disorders, 30 ; 
in meningitis, 30 ; in otitis, 30 ; in 
pneumonia, 30. 

Crying in infants, 30. 

Cryptorchidism, 51. 

Curschmann's spirals in asthma, 577. 

Cyclopia, 38. 

Cystercercus, 182. 

Cystitis, acute, 352. 

Cystitis, chronic, 353. 

Cystoidei, 183. 

Cysts of the brain, 569. 

Deaf-mutism, 592. 

Deficiency of speech from peripheral 
paralysis, 587. 

Degeneration, amyloid, of kidney, 381. 

Degeneration, fatty, of new-born, 66. 

Degeneration of kidneys, acute, 366 ; 
lesions, 366 ; symptoms, 366 ; treat- 
ment, 367. 

Degeneration of kidney, amyloid, 381. 

Degeneration of kidney, chronic, 372 ; 
causes, 372 ; lesions, 372 ; prognosis, 
374 ; symptoms, 373 ; treatment, 374. 

Delicate children, feeding of, 89, 90. 



2t 



642 



INDEX 



Delicate children, partial peptonization 

of food for, 90. 
Dementia, acute, 586. 
Dendrons, nerve, growth of, 7. 
Dentition, 96-100. 
Dentition and sickness, 98. 
Dentition, supposed effects of, 97. 
Derangement, functional, of liver, 137. 
Dermatitis exfoliativa neonatorum, 630. 
Dermatitis gangrenosa infantum, 631. 
Diabetes mellitus, 608. 
Diaphragm, hernia of the, 70. 
Diet for children of two and three years, 

93, 94. 
Difficult dentition, 97. 
Difficult dentition, lancing gums in, 

98. 
Dilatation, cardiac, 318. 
Diphtheria, 428 ; cause, 428 ; differential 

diagnosis, 440 ; lesions, 429 ; paralysis 

in, 435 ; prognosis, 439 ; symptoms, 

432 ; treatment, 436. 
Diplomyelia, 39. 
Dislocations, congenital, 51-52. 
Disorders of sleep, 588. 
Distoma crassum, 181. 
Drugs not well tolerated by children, 

36, 37. 
Drugs well tolerated by children, 37. 
Drying up of milk supply, 93. 
Duodenitis, 132. 
Duodenitis, chronic, 133 ; causes, 133 ; 

lesions, 134 ; prognosis, 135 ; symp- 
toms, 134. 
Dura mater, character of, in infants, 

5. 
Dura mater, path of infection of, 5 
Dwarfism, 214. 
Dysentery, 154-155. 

Ear, development of, 9. 

Echinococcus cysts, 182. 

Echinococcus of kidney, 387. 

Echinococcus of liver, 147. 

Echinococcus of spleen, 151. 

Echolalia, 588. 

Eczema, 625 ; causes, 625 ; lesions, 626 ; 
prognosis, 629 ; symptoms, 626 ; treat- 
ment, 628. 

Eczema of lip, 101. 

Elbow, congenital dislocation of, 52. 

Elbow, congenital dislocation, varieties, 
52. 

Elongated uvula, 242. 



Emphysema, 294 ; causes, 294 ; lesions, 
296 ; prognosis, 297 ; symptoms, 296 ; 
treatment, 297. 

Emphysema, interlobular, 295. 

Emphysema, substantive, 295. 

Emphysema, vesicular, 295. 

Empyema, 284. 

Endocarditis, acute, 305 ; causes, 305 ; 
differential diagnosis, 309; lesions, 
305 ; prognosis, 309 ; symptoms, 307 ; 
treatment, 308. 

Endocarditis, chronic, 309 ; causes, 309 ; 
lesions, 310 ; prognosis, 315 ; symp- 
toms, 310 ; treatment, 314. 

Endocarditis, chronic, aortic insuffi- 
ciency in, 312. 

Endocarditis, chronic, aortic stenosis in, 
313. 

Endocarditis, chronic, mitral stenosis 
in, 312. 

Endocarditis, chronic, mitral insuffi- 
ciency in, 31.1. 

Endocarditis, chronic, tricuspic insuf- 
ficiency in, 313. 

Endocarditis in rheumatism, 611. 

Endocarditis, malignant, 315. 

Endocarditis, mycotic, 315 ; causes, 315 ; 
differential diagnosis, 318 ; lesions, 
316 ; prognosis, 318 ; symptoms, 317 ; 
treatment, 318. 

Enteric fever, 464 ; cause, 464 ; differ- 
ential diagnosis, 471 ; lesions, 465 ; 
prognosis, 471 ; symptoms, 467 ; treat- 
ment, 470. 

Epidemic cerebro-spinal meningitis, 478; 
causes, 478 ; differential diagnosis, 
482 ; lesions, 478 ; prognosis, 482 ; 
symptoms, 479 ; treatment, 481. 

Epidemic hemoglobinuria, 65. 

Epidemic infectious parotitis, 440 ; dif- 
ferential diagnosis, 443 ; symptoms, 
441 ; treatment, 442. 

Epidemic influenza, 449 ; cause, 449 ; 
differential diagnosis, 453 ; lesions, 
449 ; prognosis, 452 ; symptoms, 449 ; 
treatment, 452. 

Epididymis, absence of, 51. 

Epididymitis, 363. 

Epiglottis, relative position of, in infant 
and adult, 11. 

Epilepsy, 595 ; differential diagnosis, 
598 ; prognosis, 597 ; symptoms, 596 ; 
treatment, 597. 

Epilepsy, masked, 597. 



INDEX 



643 



Epilepsy, procursive, 597. 

Epileptic insanity, 586. 

Epispadias, 50. 

Epistaxis, 232 ; causes, 232 ; symptoms, 

232 ; treatment, 232. 
Erb's symptom in tetany, 602, 603. 
Erosions, hemorrhagic, of the gastric 

mucous membrane, 131. 
Erosions, simple, of the mouth, 106. 
Eruption of permanent teeth, order of, 

100. 
Eruption of temporary teeth, order of, 

100. 
Erysipelas. 472 ; differential diagnosis, 

476 ; lesions, 473 ; prognosis, 475 ; 

symptoms, 473 ; treatment, 474. 
Erysipelas, ambulans, 474. 
Erysipelas, migrans, 474. 
Erythema, 623. 
Erythema in rheumatism, 613. 
Essential paralysis of children, 549. 
Eustachian tube, growth of, 9, 10. 
Examination, methods, 29. 
Exercise, outdoor, during infancy, 27. 
Eye, growth of, in infancy, 9. 
Eyes, care of, after birth, 24. 

Eace, expression of infantile, in health 
and disease, 30. 

Facial paralysis, 554. 

Eacial paralysis, obstetric, 57. 

Fallopian tubes, congenital deformities 
of, 49, 50. 

Family idiocy, amaurotic, 582. 

Fat in human milk, composition of, 73. 

Fats, excessive, effects of, 89. 

Fatty degeneration of heart, 303. 

Fatty degeneration of kidneys, 373. 

Fatty degeneration of liver, 144. 

Fatty degeneration of new-born, 66. 

Favus, 636. 

Feeding, 72. 

Feeding directly after birth, 25. 

Feeding during second year, and its con- 
tinuance, 93-94. 

Feeding during third year, 94. 

Feeding, effects of attenuated milk, 89. 

Feeding for delicate children, 89, 90. 

Feeding in acute sickness, 95. 

Feeding in first year, intervals and 
quantities, 88. 

Feeding, length of each, 89. 

Feeding of premature infants, 92. 

Feeding, scheme for, 88. 



Feeding, substitute, 77. 

Fever blisters, 629. 

Fever, scarlet, 392. 

Fever, typhoid, 464. 

Filaria sanguinis hominis, 387. 

Fingers, congenital dislocations of, 52. 

Fingers, supernumerary, 52. 

Fingers, webbed, 52. 

Fissure of the anus, 201. 

Flukes, 181. 

Flushing the lower bowel, 179. 

Follicles, lingual, growth of, 11. 

Fontanelles, closure of, 5. 

Foods, infant, 90, 91. 

Foods, infant, analysis of, 91. 

Foramen csecum, closure of, 6. 

Foramen magnum, 4. 

Foramen ovale, patent, 42. 

Forest's method of artificial respiration, 

59. 
Formulas for modifying milk, Baner's, 

83. 
Formulas for modifying milk, Chapin's, 

84, 85. 
Formulas for modifying milk, Holt's, 81. 
Freckles, 632. 
Fremitus in infants, 32. 
Friedreich's disease, 558. 
Frontal bone, ossification of, 5. 
Functional aphasia, 587. 
Functional cardiac disorders, 301. 
Furuncle of the lips, 101. 
Furunculosis, 632. 

Gaertner's bacillus, 56. 

Gall bladder, changes in position and 
activity during growth, 15. 

Gangrene of the cheek, 103 ; causes, 104 ; 
lesions, 104 ; prognosis, 105 ; symp- 
toms, 104 ; treatment, 104. 

Gangrene of the lungs, 298 ; causes, 298 ; 
lesions, 298 ; prognosis, 300 ; symp- 
toms, 299 ; treatment, 300. 

Gastralgia, 131 ; treatment, 131. 

Gastritis, acute, 119 ; causes, 119 ; le- 
sions, 120 ; symptoms, 120 ; treatment, 
121. 

Gastritis, chronic, 124 ; causes, 124 ; dif- 
ferential diagnosis, 124 ; lesions, 124 ; 
prognosis, 128 ; symptoms, 128 : treat- 
ment, 126. 

Gastritis, croupous, 122. 

Gastritis, toxic, 123 ; lesions, 123 ; treat- 
ment, 123. 



644 



INDEX 



Genitals, cleanliness of, in infants, 28. 

Genito-urinary system, diseases of, 352. 

Gingivitis, ulcerative, 106 ; causes, 106 ; 
lesions, 106 ; prognosis, 107 ; symp- 
toms, 107 ; treatment, 107. 

Glands, lymphatic, location and drain- 
age areas, 390. 

Glioma of brain, 569. 

Globus hystericus, 604. 

Glomerulo-nephritis, 367. 

Glossitis, acute, 113. 

Glossitis, simple superficial, 113. 

Glottis, oedema, 253 ; lesions, 254 ; symp- 
toms, 254 ; treatment, 254. 

Glycosuria, 33. 

Goat's milk, analysis of, 79. 

Goltz's experiment, 7. 

Gram's method of decolorization, 359. 

Grand hysteria, 604. 

Grand mal, 596. 

Grand movement, 604. 

Grippe, la, 449. 

Growing pains, 598, 609, 615. 

Habitual constipation, 188 ; causes, 188 ; 
prognosis, 191 ; symptoms, 190 ; treat- 
ment, 190. 

Hsematemesis, 132 ; differential diagno- 
sis, 132. 

Hematoma of sterno-cleido-mastoid, 
54. 

Hematuria, 34. 

Hemoglobinuria, 34 ; symptoms, 346 ; 
treatment, 346. 

Haemophilia, transmission of, 345-346. 

Hemorrhage, visceral, in new-born, 55. 

" Hemorrhagic disease" of the new- 
born, 56. 

Hemorrhagic erosions of the gastric 
mucous membrane, 131. 

Hemorrhoids, 198. 

Hare-lip, 44, 101-103. 

Hare-lip, effects of, 102. 

Hare-lip, time of operation, 103. 

Harrison's Groove, 218. 

Hay fever, 579 ; causes, 579 ; lesions, 
579 ; prognosis, 580 ; symptoms, 579 ; 
treatment, 580. 

Headaches, 606. 

Heart, comparative size, to that of arte- 
ries, 13-14. 

Heart, congenital malformations, 41. 

Heart, development of, 12-13. 

Heart disease, congenital, symptoms, 43. 



Heart disease, prognosis in congenital, 
43. 

Heart, diseases of, 301. 

Heart, fatty, 393. 

Heart, increase of size and weight, 14. 

Heart, murmurs in childhood, 32. 

Heart, relative size in infant and adult, 
13. 

Heart, relation of volume to aorta at 
different stages, 14. 

Henoch's purpura, 348-350. 

Hepatitis, interstitial, 141 ; causes, 141 ; 
lesions, 142 ; symptoms, 143 ; treat- 
ment, 143. 

Hepatitis, parenchymatous, 139. 

Hepatitis, purulent, 139 ; differential 
diagnosis, 140 ; symptoms, 140 ; treat- 
ment, 141. 

Herd-milk, 79. 

Hereditary ataxias, 358. 

Hereditary ataxic paraplegia, 560. 

Hereditary cerebellar ataxia, 559. 

Hereditary spinal ataxia, 558. 

Hermaphroditism, 50-51. 

Hernia of the diaphragm, 70. 

Hernia, umbilical, 68. 

Herpes of lips, 101. 

Herpes simplex, 629. 

Herpes Zoster, 629. 

Heteropia, 39. 

Hip, congenital dislocations of, 51. 

History of disease as obtained from 
mother or nurse, 29. 

Hives, 631. 

Hodgkin's disease, 342. 

Holt's cream gauge, 75. 

Holt's formulas for modifying milk, 81. 

Human milk, analysis of, 72, 74. 

Hydrocele, 363 ; varieties of, 363-364. 

Hydrocephalus, 573 ; differential diagno- 
sis, 575 ; lesions, 574 ; symptoms, 574 ; 
treatment, 575 ; varieties of, 573. 

Hydromyelia, 544. 

Hydromyelia externa, 39. 

Hydromyelocele, 39. 

Hydronephrosis, 386. 

Hydrorrachis externa, 39. 

Hydrotherapy for children, 37. 

Hygiene of new-born child, 24. 

Hymen, irregular formation of, 48. 

Hyperidrosis, 622. 

Hypertrophy, cardiac, 318. 

Hypochondriasis, 586. 

Hypospadias, 50. 



IXDEX 



645 



Hysteria, 603 ; differential diagnosis, 
006 ; prognosis, 605 ; symptoms, 604 ; 
treatment, 605. 

Hysteria major, 604. 

Hystero-epilepsy, 604. 

Icterus. 136. 

Icterus neonatorum, 61-62. 

Icthyosis, 633. 

Idiocy, 583. 

Idiocy, amaurotic family, 582. 

Idiocy, Shuttle worth's classification of, 
584. 

Ileo-colitis, acute, 153 ; causes, 154 ; 
differential diagnosis, 161 ;• lesions, 
155 ; prognosis, 161 ; symptoms, 157 ; 
treatment, 159. 

Heo-colitis, chronic, 161 ; differential 
diagnosis, 164 ; lesions, 161 ; prog- 
nosis, 164 ; symptoms, 162 ; treat- 
ment, 163. 

Heo-colitis due to amoebic infection, 164 ; 
lesions, 164 ; prognosis, 165 ; symp- 
toms, 165 ; treatment, 165. 

Impetigo contagiosa, 630. 

Incontinence of urine, 354. 

Incubator, Rotch's, 92. 

Incubators, 92. 

Indican, 54. 

Infant foods, 90, 91. 

Infant foods, analyses of, 91. 

Infantile eerebral paralysis, 561 ; causes, 

562 ; differential diagnosis, 565 ; le- 
sions, 562 ; prognosis, 564 ; symptoms, 

563 ; treatment, 564. 

Infantile pseudo-leucpemic anaemia, 337. 

Infantile scurvy, 225 ; causes, 225 ; 
differential diagnosis, 227 ; lesions, 
225 ; prognosis, 227 ; symptoms, 226 ; 
treatment, 227. 

Infantile spinal paralysis, 549 ; differ- 
ential diagnosis, 551 ; lesions, 549 ; 
prognosis, 551 ; symptoms, 550 ; treat- 
ment. 550. 

Infantilism. 214. 

Infants, premature, care of, 91, 92. 

Infants, premature, feeding of, 92. 

Infarction of kidney, 383. 

Infection, acute pyogenic, 62. 

Infectious derangements of the intes- 
tines, 166 ; causes, 166 ; differential 
diagnosis, 169 ; lesions, 166 ; prog- 
nosis, 170 ; symptoms, 167 ; treat- 
ment, 169. 



Infectious haemoglobinaemia, 65. 

Infectious hsemoglobinsemia, lesions. 65. 

Infectious haeruoglobmaeniia, symptoms, 
65. 

Inflammations of the middle ear, 617 ; 
causes, 617 ; complications, 618 ; le- 
sions, 617 ; prognosis, 620 ; symptoms, 
618 ; treatment, 619. 

Influenza, epidemic, 449. 

Inherited syphilis, 515. 

Inhibitory centres, development of, 7. 

Insanity, cataleptic, 586. 

Insanity, epileptic, 586. 

Insanity, in childhood, 585 ; causes, 585 ; 
forms of, 586. 

Insanity, moral. 586. 

Insanity, periodic, 586. 

Insufficiency in heart disease, 311. 

Intellectual impulses, comparative devel- 
opment of. 7. 

Intertrigo, 627. 

Intestinal colic in infants. 187. 

Intestinal obstruction in the new-born, 
69. 

Intestine, changes in glands during 
growth, 18. 

Intestine, congenital malformations, 45. 

Intestine, growth and development, 18. 

Intestine, large, diseases of, 153. 

Intestine, small, diseases of, 117. 

Intestines, chronic functional derange- 
ments of, 173. 

Intestines, infectious derangements of, 
166. 

Intestines, subacute infection of, 170. 

Intracranial sinuses, thrombosis of, 565. 

Intubation, feeding in, 437-439. 

Intussusception, 177 ; causes, 177 ; dif- 
ferential diagnosis, 179 ; lesions, 177 ; 
prognosis, 179 ; symptoms, 178 ; treat- 
ment, 179. 

Jaundice, 136. 

Jaws, development of, 5. 

Kernig's sign in epidemic cerebro-spinal 

meningitis, 481, 482. 
Kidney, blended, 47. 
Kidney, horseshoe, 47. 
Kidney, increase in calibre of arterial 

system, 17. 
Kidney, infarction of, 383. 
Kidney, new growths of, 387. 
Kidney, parasites of, 387. 



646 



INDEX 



Kidney, uric acid in infants, at birth, 

17. 
Kidneys, acute congestion of, 365. 
Kidneys, acute degeneration of, 366. 
Kidneys, amyloid degeneration of, 381. 
Kidneys, chronic congestion of, 372. 
Kidneys, chronic degeneration of, 372. 
Kidneys, congenital absence of, 47. 
Kidneys, congenital deformities of, 47. 
Kidneys, diseases of, 365. 
Kidneys, growth and development of, 

16. 
Kleptomania, 586. 
Knee, congenital dislocations of, 52. 
Kumyss, 95. 

Laborde's lingual traction, 60. 

Lachrymal glands, growth of, 9. 

Lancing gums in difficult dentition, 
98. 

Landry's paralysis, 561. 

Large intestine, diseases of, 153. 

Laryngismus stridulus, 209 ; causes, 209 ; 
lesions, 210 ; prognosis, 211 ; symp- 
toms, 210 ; treatment, 211. 

Laryngitis, acute, 249 ; prognosis, 250 ; 
symptoms, 249 ; treatment, 250. 

Laryngitis, chronic, 250 ; causes, 250 ; 
lesions, 251 ; prognosis, 251 ; symp- 
toms, 251 ; treatment, 251. 

Laryngitis, pseudo-membranous, 251. 

Laryngitis, spasmodic, 252 ; causes, 252 ; 
lesions, 252 ; prognosis, 253; symp- 
toms, 252 ; treatment, 253. 

Larynx, congenital malformations of, 
40. 

Larynx, development of, 11. 

Late rachitis, 222. 

Lateral sinus, thrombosis of, 566. 

Lentigo, 632. 

Leptomeningitis, acute, 537 ; causes, 

537 ; differential diagnosis, 539 ; le- 
sions, 537 ; prognosis, 538 ; symptoms, 

538 ; treatment, 538. 
Leptomeningitis, chronic, 539 ; differ- 
ential diagnosis, 540 ; lesions, 539; 
prognosis, 540 ; symptoms, 539 ; treat- 
ment, 539. 

Leucocythsemia, 338 ; causes, 339 ; dif- 
ferential diagnosis, 342 ; lesions, 339 ; 
prognosis, 342 ; symptoms, 341 ; treat- 
ment, 344. 

Leyden's crystals in asthma, 577. 

Lichen tropicus, 624. 



Lips, diseases of, 101. 

Lips, eczema of, 101. 

Lips, furuncle of, 101. 

Lips, herpes of, 101. 

Lisping, 587. 

Lithuria, 34. 

Liver, acute yellow atrophy of, 143. 

Liver, amyloid degeneration of, 145. 

Liver, changes during growth, 14. 

Liver, changes in position, 15. 

Liver, congenital malformation of, 46. 

Liver, congestion of, 138. 

Liver, diseases of, 136. 

Liver, echinococcus, infection of, 147 ; 

differential diagnosis, 148 ; symptoms, 

167 ; treatment, 148. 
Liver, fatty, 144. 

Liver, functional derangements of, 137. 
Liver, waxy, 145. 
Liver, wounds of, 148. 
Lobar pneumonia, 453 ; causes, 454 ; 

differential diagnosis, 463 ; lesions, 455; 

prognosis, 463 ; symptoms, 457 ; treat- 
ment, 461. 
Longet's experiment, 7. 
Lungs, congenital malformation, 41. 
Lungs, development of, 16. 
Lungs, diseases, 255. 
Lungs, gangrene of, 299. 
Lungs, size relative to heart at different 

ages, 16. 
Lymph-adenitis, retro-oesophageal, 115. 
Lymph-adenitis, retro-pharyngeal, 246, 
Lymphatic glands, location and drainage 

areas, 390. 

Macrochilia, 101. 

Macroglossia, 47, 101. 

Macula lutea, growth of, 9. 

Malaria, 528 ; causes, 528 ; differential 
diagnosis, 534 ; lesions, 528 ; prog- 
nosis, 534 ; symptoms, 531 ; treatment, 
533. 

Malnutrition, diseases of, 209. 

Mamma, deformities, 50. 

Mamma, supernumerary, 50. 

Mania, 586. 

Mare's milk, analysis of, 79. 

Marie's disease, 559. 

Masked epilepsy, 597. 

Mastitis in infants, 68. 

Mastoid cells, development of, 9. 

Mastoiditis, 618. 

Masturbation, 591. 



INDEX 



647 



Matema milk-modifying apparatus, 84. 

Matzoon, 96. 

Maxilla, inferior, congenital dislocation 
of, 52. 

Measles, 405 ; causes, 405 ; differential 
diagnosis, 413 ; incubation, 406 ; 
lesions, 406 ; prognosis, 413 ; treat- 
ment, 411. 

Measles, German, 414. 

Meckel's diverticulum, 45, 67. 

Medulla oblongata, medullation of, 7. 

Melancholia, 586. 

Meningitis, epidemic cerebro-spinal, 478. 

Meningitis, spinal, 542. 

Meningocele, spinal, 39. 

Meningo-myelocele, 39. 

Microcephalus, 38. 

Microglossia, 44. . 

Miliaria, 624. 

Milk, ass's, analysis of, 79. 

Milk, bacteriology of, 76. 

Milk, boiled, 86. 

Milk, cow's, analysis of, 79. 

Milk, cow's, for modification, 79-80. 

Milk, cow's, modification of, 80. 

Milk, goat's, analysis of, 79. 

Milk, human, analysis of, 72, 74. 

Milk, human, instability of, 76. 

Milk, human, regulation of, 77. 

Milk laboratories, 86. 

Milk, mare's, analysis of, 79. 

Milk, pasteurized, 87. 

Milk, practical asepsis of, 87. 

Milk spot, 13. 

Milk, sterilized, 86. 

Milk supply, drying up of, 93. 

Milk, unboiled, value of, 87. 

Milk, variations in, 76. 

Mineral matters in human milk, com- 
position of, 74. 

Mitral insufficiency in chronic endocar- 
ditis, 311. 

Mitral stenosis in chronic endocarditis, 
312. 

Moist dressings, use of, 37. 

Mole, 634. 

Moral insanity, 586. 

Morbilli, 405. 

Morbus sacer, 495. 

Morbus virgineus, 331. 

Mouth, cleansing of, in infants, 25. 

Mouth, congenital malformation, 44. 

Mouth, diseases of, 101. 

Mouth, simple erosions of, 106. 



Multiple neuritis, 552 ; causes, 552 ; 

differential diagnosis, 555 ; lesions, 

552 ; prognosis, 555 ; symptoms, 552 ; 

treatment, 554. 
Mumps, 440. 
Murmur, in congenital heart disease, 

43. 
Murmurs, anaemic, 321. 
Muscles, character of, in infants, 4. 
Myelitis, 544 ; differential diagnosis, 

546 ; lesions, 544 ; prognosis, 546 ; 

symptoms, 545 ; treatment, 545. 
Myelosyringosis, 543. 
Myocarditis, 302 ; causes, 302 ; lesions, 

303 ; symptoms, 304 ; treatment, 304. 
Myocarditis, purulent form of, 303. 
Myxo-glioma of brain, 369. 

Nsevus of the rectum, 199. 

Naevus pigmentosus, 634. 

Nasal polypi, 233. 

Nemathelminthes, 181, 184. 

Nephritis, acute diffuse, 369 ; causes, 
369 ; lesions, 369 ; prognosis, 372 ; 
symptoms, 369 ; treatment, 371. 

Nephritis, acute exudative, 367 ; lesions, 
367 ; treatment, 368. 

Nephritis, catarrhal, 367. 

Nephritis, chronic diffuse, with exuda- 
tion, 377 ; lesions, 377 ; symptoms, 
378. 

Nephritis, chronic diffuse, without exu- 
dation, 374 ; lesions, 374 ; prognosis, 
376 ; symptoms, 374 ; treatment, 376. 

Nephritis, croupous, 367. 

Nephritis, desquamative, 367. 

Nephritis, glomerulo-, 367. 

Nephritis, parenchymatous, 367. 

Nephritis, pyelo-, chronic, 381. 

Nephritis, suppurative, 379; lesions, 380; 
prognosis, 381 ; symptoms, 380 ; treat- 
ment, 381. 

Nerve medullation, development of, 7. 

Nettle rash, 631. 

Neurasthenia, 586. 

Neurons, growth of, 7. 

New growths of kidney, 387. 

Nightmare, 589. 

Night terror, 589. 

Nipples, nursing, care of, 88. 

Nipples, supernumerary, 50. 

Nodules, subcutaneous, in rheumatism, 
610-612. 

Noma, 103. 



648 



INDEX 



Nose, diseases of, 229. 

Nurse, selection of, 28. 

Nursing bottles, care of, 88. 

Nursing, frequency and duration of, 

27. 
Nursing, intervals between, 77. 
Nursing nipples, care of, 88. 

Obstetric paralyses, 56. 

Obstruction, intestinal, in the new-born, 

69. 
CEdema, in infant, 71. 
(Edema of the glottis, 253. 
(Esphagitis, acute, 114. 
CEsophagus, congenital malformation, 

45. 
CEsophagus, diseases of, 101. 
Ophthalmia neonatorum, 63 ; symptoms, 

64 ; trea+ment, 64. 
Opium, use of, in children, 35. 
Orchitis, 363. 
Order of eruption of permanent teeth, 

100. 
Order of eruption of temporary teeth, 

100. 
Otitis media, 617. 

Outdoor exercise, during infancy, 27. 
Ovary, congenital deformities of, 49-50. 
Oxyuris vermicularis, 186 ; symptoms, 

186 ; treatment, 186. 

Pachymeningitis, 540 ; symptoms, 540- 
541 ; treatment, 541. 

Pachymeningitis, acute, external, 540. 

Pachymeningitis, acute, internal, 540. 

Pachymeningitis, chronic, 541. 

Palate, soft, development of, 11. 

Pancreas, congenital deformities of, 47. 

Pancreas, diseases of, 136. 

Paralyses, obstetric, 56. 

Paralysis, acute, 561. 

Paralysis, Bell's, 554. 

Paralysis, essential, of children, 549. 

Paralysis, facial, 554. 

Paralysis, false, of inherited syphilis, 
524. 

Paralysis, infantile cerebral, 561. 

Paralysis, Landry's, 561. 

Paranoia, 586. 

Paraplegia, hereditary ataxic, 560. 

Paraphimosis, 358. 

Parasites of kidney, 387. 

Parenchymatous degeneration of kid- 
ney, 366. 



Parenchymatous inflammation of kid- 
ney, 366. 

Parotitis, 440. 

Pasteurization of milk, 87. 

Pavor nocturnus, 589. 

Pediculosis, 638. 

Peliosis rheumatica, 348. 

Peliosis rheumatica of Schcenlein, 550. 

Pelvic viscera, changes in position during 
growth, 19. 

Pelvis, changes during growth, 19. 

Pemphigus in infants, 66 ; symptoms, 
67 ; treatment, 67. 

Penis, deformities of, 50. 

Peptonization of food, 95. 

Peptonization, partial, for delicate chil- 
dren, 90. 

Percentage of water ip foetus, 3. 

Percentage of water in new-born infant, 3. 

Percussion, method and results of, 32. 

Pericarditis, acute, 321 ; causes, 322 ; 
differential diagnosis, 327 ; lesions, 
323 ; prognosis, 327 ; symptoms, 324 ; 
treatment, 326. 

Pericarditis, chronic, 327 ; lesions, 327 ; 
prognosis, 328; symptoms, 327 ; treat- 
ment, 327. 

Pericarditis, fibrinous, 323. 

Pericarditis, hgemorrhagic, 324. 

Pericarditis in rheumatism, 611. 

Pericarditis, purulent, 323. 

Pericarditis, serous, 323. 

Pericarditis, simple, 323. 

Perihepatitis, in chronic peritonitis, 206. 

Perinephritis, 384 ; causes, 384 ; differ- 
ential diagnosis, 384 ; lesions, 384 ; 
prognosis, 385 ; symptoms, 385 ; treat- 
ment, 385. 

Perinephritis in chronic peritonitis, 206. 

Periodic insanity, 586. 

Periosteum, in infant and adult, 4. 

Peripheral nerves, medullation of, 7. 

Peripheral paralysis, obstetric, 57. 

Perisplenitis in chronic peritonitis, 206. 

Peritonaeum, congenital malformation 
of, 46. 

Peritonaeum, diseases of, 202. 

Peritonitis, acute, 202 ; causes, 202 ; 
differential diagnosis, 205 ; lesions, 
203 ; prognosis, 205 ; symptoms, 203 ; 
treatment, 204. 

Peritonitis, chronic, 206 ; lesions, 206 ; 
prognosis, 208 ; symptoms, 207 ; treat- 
ment, 207. 



INDEX 



649 



Peritonitis, chronic, laparotomy in, 
207. 

Peritonsillar abscess, 241. 

Pernicious anaemia, 337. 

Pertussis, 443 ; causes, 443 ; differential 
diagnosis, 448 ; lesions, 443 ; progno- 
sis, 448 ; symptoms, 444 ; treatment, 
446. 

Petit mal, 596. 

Petrosal sinus, thrombosis of, 597. 

Petro-squamosal suture, closure of ex- 
ternal, 9. 

Pharyngeal vault, adenoid vegetations 
of, 234 ; causes, 234 ; lesions, 234 ; 
prognosis, 236 ; symptoms, 235 ; treat- 
ment, 236. 

Pharyngitis, acute, 243 ; causes, 243 ; 
lesions, 243 ; symptoms, 244 ; treat- 
ment, 244. 

Pharyngitis, chronic, 244 ; causes, 244 ; 
lesions, 245 ; symptoms, 245 ; treat- 
ment, 245. 

Phimosis, 358. 

Physiological icterus, 61. 

Physiological mastitis, 69. 

Platyhelminthes, 181. 

Pleura, diseases of, 255. 

Pleurisy, acute, 279 ; causes, 280 ; com- 
plications, 288 ; differential diagnosis, 
289 ; lesions, 281 ; prognosis, 289 ; 
symptoms, 284 ; treatment, 288. 

Pleurisy, chronic, 290 ; causes, 290 ; 
lesions, 290 ; symptoms, 290 ; treat- 
ment, 290. 

Pleurisy, dry, 282. 

Pleurisy, fibrinous, 282. 

Pleurisy, purulent, 284. 

Pleurisy with effusion, 283. 

Pleuritic fluid, 282. 

Pneumonia, croupous, 453. 

Pneumonia, fibrinous, 453. 

Pneumonia, interstitial, 274 ; causes, 
274 ; differential diagnosis, 276 ; 
lesions, 274 ; prognosis, 276 ; symp- 
toms, 275 ; treatment, 276. 

Pneumonia, lobar, 453. 

Pneumonia, secondary, 276 ; causes, 
276 ; lesions. 277 ; prognosis, 277 ; 
symptoms, 277 ; treatment, 277. 

Pneumotomy in bronchiectasis, 279. 

Poliomyelitis, acute anterior, 549. 

Polymazia, 50. 

Polypi, nasal, 233. 

Polypus of rectum, 200. 



Polypus, umbilical, 67. 

Polythelia, 50. 

Polyuria, 34 ; treatment, 34. 

Porencephalies, 38. 

Portal vein, injury of, 148. 

Post-hemiplegic polymyo-clonus of Pe- 
terson, 564. 

Poultices, use of, 37. 

Pons Varolii, medullation of, 7. 

Predigestion of food, 95. 

Premature infants, care of, 91-92. 

Premature infants, feeding of, 92. 

Prescription writing for children, 36. 

Prickly heat, 624. 

Proctitis, 196 ; membranous form, 197 ; 
ulcerative form, 197. 

Procursive epilepsy, 597. 

Progressive muscular atrophies, 556 ; 
Aran-Duchenne type, 556 ; Charcot- 
Marie-Tooth type. 557 ; Erb's type, 
557 ; Landouzy-Dejerine type, 558. 

Prolapse of anus and rectum, 197 ; 
causes, 197 ; treatment, 198. 

Proportions of infant as compared with 
those of adult, 3. 

Proteids, determination of, in milk 
analysis, 75. 

Proteids, excessive, effects of, 89. 

Proteids- in human milk, composition of. 
73. 

Pseudo-hermaphroditism, 51. 

Pseudo-leucaemia, 342; differential diag- 
nosis, 344 ; lesions, 342 ; prognosis, 
344; symptoms, 343; treatment, 344. 

Pseudo-tetanus, 601. 

Ptyalin-forming glands in infancy, 11. 

Pulmonary artery, relation of pressure 
to that of aorta at different stages, 14. 

Pulmonary artery, stenosis, 42. 

Pulse, character of, in infant, 3. 

Purkinje's cells, development of. 6. 

Purpura, 347; differential diagnosis, 351; 
prognosis, 351; treatment, 351. 

Purpura, kasmorrhagic, 348-349. 

Purpura, haemorrhagic, in rheumatism, 
613. 

Purpura, infective group of, 348. 

Purpura, mechanical group of, 348: 

Purpura, nervous group of, 348. 

Purpura, primary, 348. 

Purpura, toxic group of, 348. 

Pyelo-nephritis, chronic, 381. 

Pyromania, 586. 

Pyuria, 34. 



650 



INDEX 



Quincke's lumbar puncture in epidemic 
cerebrospinal meningitis, 482. 

Rachitic girdle, 218. 

Rachitic rosary, 219. 

Rachitis, 214 ; causes, 214 ; differential 
diagnosis, 214 ; lesions, 216 ; progno- 
sis, 224 ; symptoms, 18 ; treatment, 
222. 

Rachitis, congenital, 222. 

Rachitis, craniotabes in, 217. 

Rachitis, late, 222. 

Recessus opticus, 9. 

Rectal abscess, 199. 

Rectal polypus, 200. 

Rectum, changes in, during growth, 19. 

Rectum, nsevus of, 199. 

Rectum, prolapse of, 197. 

Red gum, 624. 

Renal calculi, 388. 

Respiration, artificial, Forest's method 
of, 59 ; Schultze's method of, 59 ; Syl- 
vester's method of, 60. 

Respiration in infants, 3, 30. 

Retro-cesophageal lymph-adentis, 115 ; 
prognosis, 116 ; treatment, 115. 

Retro-pharyngeal abscess, 246-247. 

Retro-pharyngeal lymph-adenitis, 246, 
248 ; causes, 246 ; prognosis, 248 ; 
symptoms, 247 ; treatment, 248. 

Rheumatism, 609 ; causes, 609 ; differ- 
ential diagnosis, 615 ; lesions, 610 ; 
prognosis, 614 ■ symptoms, 610 ; treat- 
ment, 613. 

Rheumatism, in connection with chorea, 
612. 

Rheumatoid arthritis, 615. 

Rhinitis, acute, 229 ; causes, 229 ; lesions, 
229'; prognosis, 230 ; symptoms, 229 ; 
treatment, 230. 

Rhinitis, chronic, 230 ; causes, 230 ; 
lesions, 231 ; prognosis, 232 ; symp- 
toms, 231; treatment, 231. 

Ribemont's laryngeal inflation, 60. 

Ribs, development of, 12. 

Ringworm, 635. 

Rolando, development of fissure of, 6. 

Romberg's symptom in multiple neuritis, 
553. 

Rose cold, 579. 

Rotheln, 414. 

Rubella, 414 ; cause, 414 ; differential 
diagnosis, 415 ; symptoms, 414 ; treat- 
ment, 415. 



Salivary glands in infancy, 11. 

Sarcoma of brain, 569 ; varieties of, 
569. • 

Scabies, 637. 

Scarlatina, 392. 

Scarlet fever, 392 ; causes, 392 ; compli- 
cations, 399-401 ; differential diagno- 
sis, 404 ; lesions, 393 ; prognosis, 403 ; 
symptoms, 394, treatment, 402. 

Scarlet fever, arthritis in, 401. 

Scarlet fever, cerebral, 400. 

Schcenlein's peliosis rheumatica, 350. 

Schultze's method of artificial respira- 
tion, 60. 

Sclerema neonatorum, 70. 

Scleroderma, 621. 

Scurvy, infantile, 225. 

Seborrhcea, 621. 

Seminal vesicles, absence of, 51. 

Shingles, 629. 

Shoulder joint, congenital dislocation 
of, 52 ; subacromial, 52 ; subcoracoid, 
52 ; subglenoid, 52 ; subspinous, 52. 

Simple atrophy, 211 ; causes, 211 ; differ- 
ential diagnosis, 213 ; prognosis, 213 ; 
symptoms, 212 ; treatment, 213. 

Simple herpes, 629. 

Sinus, thrombosis of cavernous, 566. 

Sinus, thrombosis of lateral, 566. 

Sinus, thrombosis of petrosal, 566. 

Sinus, thrombosis of superior longitudi- 
nal, 566. 

Sinuses, development of frontal, 6. 

Sinuses, thrombosis of intra-cranial, 565. 

Skin, diseases of the, 621. 

Skoda's resonance, 285. 

Skull, comparative proportions in infant 
and adult, 5. 

Skull, development of, 4. 

Sleep, best position for infant, 26. 

Sleep, disorders of, 588. 

Sleep, necessity of, for infant, 26. 

Sleep, regular hours for, 27. 

Small-pox, 417. 

Somatic impulses, comparative develop- 
ment of, 7. 

Soxhlet's method of milk analysis, 74. 

Speech, backwardness in acquiring, 588. 

Speech, deficiency of, from peripheral 
paralysis, 587. 

Spermatic cord, absence of, 51. 

Sphenoid and occipital bones, closure 
of, 5. 

Spina bifida, 39; treatment, 40. 



INDEX 



651 



Spinal cord, comparative length of, 8. 

Spinal cord, compression of, 546. 

Spinal cord, congenital malformation of, 
39. 

Spinal cord, medullation of, 7. 

Spinal cord, tumors of, 572. 

Spinal meningitis, 542. 

Spleen, amyloid degeneration of, 151. 

Spleen, changes during growth, 15. 

Spleen, congenital deformities of, 47. 

Spleen, congestion of, 149. 

Spleen, diseases of, 136. 

Spleen, echinococcus of, 151. 

Spleen, in diaphragmatic hernia, 47. 

Spleen, parasites of, 151. 

Spleen, transposition of, 47. 

Spleen, waxy, 151. 

Spleen, wounds of, 151. 

Sporadic cretinism, 580 ; symptoms, 581 ; 
treatment, 581. 

Sprue, 110. 

Stammering, 588. 

Stenosis of orifices in heart disease, 
311. 

Stenosis of pulmonary artery, 42. 

Sterilization of milk, 86. 

Sterno-cleido-mastoid, hsematoma of, 54. 

Stomach, acute functional derangement 
of, 117, 118 ; lesions, 118 ; prognosis, 
119; symptoms, 118; treatment, 118. 

Stomach, changes in glands of, during 
growth, 17. 

Stomach, changes in shape and size 
during growth, 17. 

Stomach, congenital malformations of, 
45. 

Stomach, dilatation of, 128 ; prognosis, 
129 ; symptoms, 128 ; treatment, 129. 

Stomach, diseases of, 117. 

Stomach, ulcer of, 129 ; causes, 129 ; 
lesions, 130; prognosis, 131; symp- 
toms, 130 ; treatment, 131. 

Stomatitis, acute, simple, 108 ; causes, 
108 ; lesions, 108 ; symptoms, 108 ; 
treatment, 109. 

Stomatitis, croupous, 111 ; causes, 111 ; 
lesions, 112 ; prognosis 112 ; symp- 
toms, 112 ; treatment, 112. 

Stomatitis, gangrenosa, 103. 

Stomatitis, gonorrhceal, 112. 

Stomatitis, herpetoid, 109 ; lesions, 109 ; 
prognosis, 110 ; symptoms, 109 ; treat- 
ment, 110. 

Stomatitis, mycetogenetic, 110 ; causes, 



110 ; lesions, 110 ; prognosis, 110 ; 
symptoms, 110. 

Strawberry tongue in scarlet fever, 397. 

Stricture of the urethra in boys, 362. 

Strongylus gigas, 387. 

Stuttering, 587. 

St. Vitus dance, 598. 

Subacute intestinal infection, ]70 ; 
lesions, 170 ; prognosis, 173 ; symp- 
toms, 171 ; treatment, 172. 

Subarachnoid space in infant and adult, 
5-6. 

Subluxations, congenital, 52. 

Subphrenic abscess, 148. 

Substitute feeding, 77. 

Sucking, adventitious, 590. 

Sudamina, 625. 

Sugar, deficient, effects of, 89. 

Sugar in human milk, 74. 

Superior longitudinal sinus, thrombosis 
of, 566. 

Supernumerary fingers, 52. 

Supernumerary mammse, 50. 

Supernumerary nipples, 50. 

Supernumerary toes, 52. 

Suprarenal capsules, congenital deform- 
ities of, 47. 

Suprarenal capsules, development of, 
17. 

Suture, petro-squamous, patency of, 5. 

Sylvester's method of artificial respira- 
tion, 59. 

Sylvian fissure, development of, 6. 

Symptoms of congenital heart disease, 
43. 

Syphilis, inherited, 515 ; causes, 515 ; 
differential diagnosis, 527 ; lesions, 
516 ; prognosis, 527 ; symptoms, 520 ; 
treatment, 526. 

Syphilis, late hereditary, 525. 

Syringomyelia, 543. 

Syringomyelocele, 40. 

Table (Boas) of weight and height, 
22-23. 

Table of differential diagnosis between 
scarlet fever, measles, varicella, vari- 
ola, and rubella, 424. 

Table of dimensions of boys, 20. 

Table of dimensions of girls, 21. 

Table (Quetelet) of height and weight, 22. 

Taenia canina, 183. 

Taenia cucumerina, 183. 

Taenia echinococcus, 183. 



652 



INDEX 



Taenia elliptica, 183. 

Taenia flavo-punctata, 183. 

Taenia inermis, 182. 

Taenia madagascariensis, 183. 

Taenia mediocanellata, 182. 

Taenia nana, 183. 

Taenia saginata, 182. 

Taenia solium, 182. 

Taeniarhynchus mediocanellatus, 182. 

Tachycardia, 301. 

Tapeworms, 181. 

Teeth, development of, 10, 99. 

Teeth, permanent, order of eruption, 100. 

Teeth, temporary, order of eruption, 100. 

Teething, 96-100. 

Teething, supposed effects of, 97, 

Temperature, elevation of, in infants 
and children, 30. 

Temporal bone, relation of squamous 
and parietal portions in infant and 
adult, 5. 

Testicles, deformities of, 51. 

Tetanilla, 601. 

Tetanus, 476 ; prognosis, 477 ; symp- 
toms, 476 ; treatment, 477. 

Tetanus, pseudo-, 601. 

Tetany, 601 ; differential diagnosis, 603 ; 
prognosis, 603 ; symptoms, 602 ; treat- 
ment, 603. 

Therapeutic suggestions, 35. 

Thorax, comparative dimensions of 
infant and adult, 12. 

Throat, diseases of, 229. 

Thrombosis of cavernous sinus, 566. 

Thrombosis of lateral sinus, 566. 

Thrombosis of petrosal sinus, 566. 

Thrombosis of superior longitudinal 
sinus, 566. 

Thrombosis of the intracranial sinuses, 
565. 

Thrush, 110. 

Thymus gland, atrophy of, 11. 

Thymus gland, at birth, 11. 

Thyroid gland, atrophy of, 11. 

Tinea favosa, 636. 

Toes, supernumerary, 52. 

Toes, webbed, 52. 

Tongue, coated, 113. 

Tongue, geographical, 113. 

Tongue, growth of, 11. 

Tongue, hairy, 113. 

Tongue, strawberry, 113. 

Tongue, strawberry, in scarlet fever, 397. 

Tonsil, Luschka's, 234. 



Tonsil, pharyngeal, at birth, 11. 

Tonsil, pharyngeal, hypertrophy of, 234. 

Tonsil, third, 234. 

Tonsillitis, acute follicular, 238 ; differ- 
ential diagnosis, 239 ; lesions, 238 ; 
prognosis, 239 ; symptoms, 238 ; treat- 
ment, 239. 

Tonsillitis, acute simple, 236 ; lesions, 
237 ; prognosis, 238 ; symptoms, 237 ; 
treatment, 237. 

Tonsils, chronic inflammation and hy- 
pertrophy of, 240 ; lesions, 240 ; symp- 
toms, 240 ; treatment, 241. 

Torticollis, congenital, 55 ; from haema- 
toma, 55. 

Trachea, relative position of, 11-12. 

Trematoda, 181. 

Trichina cystica, 387. 

Trichodectes canis, 183. 

Tricuspic insufficiency in chronic endo- 
carditis, 313. 

Trousseau's symptom in tetany, 602-603. 

Tubes, Fallopian, deformities of, 50. 

Tuberculosis, 484 ; differential diagnosis, 
513 ; heredity of, 484 ; inoculation of, 
485. 

Tuberculosis, lesions, 486 ; lesions in 
cerebral, 497 ; lesions in gastric, 495 ; 
lesions in glandular, 491 ; lesions in 
hepatic, 494 ; lesions in intestinal, 495 ; 
lesions in mesenteric 495 ; lesions in 
nephritic, 493 ; lesions in osseous, 493 ; 
lesions in peritoneal, 496 ; lesions in 
pleuritic, 490 ; lesions in pulmonary, 
487 ; lesions in splenic, 494 ; lesions 
in placental, 484. 

Tuberculosis, prognosis in, 512. 

Tuberculosis, symptoms, 498 ; symptoms 
in adenitis, 502 ; symptoms in cere- 
bral, 506 ; symptoms in gastric, 505 ; 
symptoms in miliary, 499 ; symptoms 
in nephritic, 504 ; symptoms in osse- 
ous, 503 ; symptoms in peritoneal, 
505 ; symptoms in pleuritic, 502 ; 
symptoms in pulmonary, 499. 

Tuberculosis, treatment of, 509. 

Tuberculosis, treatment in adenitis, 512 ; 
treatment, diet, 511 ; treatment, spe- 
cial methods of, 511. 

Tumor of brain, cystic, 569. 

Tumor of brain, gliomatous, 569. 

Tumor of brain, myxo-gliomatous, 569. 

Tumor of brain, sarcomatous, 569. 

Tumor of brain, tubercular, 566. 



IXDEX 



653 



Tumor of the brain, 568 ; differential 
diagnosis, 571 ; prognosis, 571 ; symp- 
toms, 569; treatment, 571. 

Tumors of the spinal cord, 572. 

Typhoid fever, 464. 

Ulcerative gingivitis, 106. 

Ulcerative stomatitis, 106. 

Umbilical hernia, 68. 

Umbilical polypus, 67. 

Umbilicus, diverticulum, tumor of, 67. 

Urachus, patent, 48. 

Ureters, congenital deformities of, 47. 

Urethra, congenital deformities of, 

48. 
Urethritis, in male children, 359 ; symp- 
toms, 360 ; treatment, 360. 
Uric acid, quantity of, at different ages, 

32. 
Urination, regulation of, in infancy, 

27. 
Urine, collection of, in infants, 32. 
Urine, different constituents, at different 

ages, 33. 
Urine, incontinence of, 354 ; prognosis, 

356 ; treatment, 355. 
Urine, quantity in 24 hours, at different 

ages, 33. 
Urticaria, 631. 

Uterus, congenital deformities of, 49. 
Uvula, bifid, 602. 
Uvula, elongated, 242. 
Uvula, growth of, 11. 
Uvulitis, 242. 

Vaccinia, 424. 

Vagina, congenital deformities of, 

49. 
Varicella, 415 ; differential diagnosis, 

417 ; symptoms, 416 ; treatment, 

417. 
Variola, 417 ; causes, 418 ; differential 

diagnosis, 424 ; prognosis, 423 ; symp- 



toms, 418 ; treatment, 422 ; varieties 
of, 419. 

Varioloid, 424-427. 

Ventilation, of nursery, for infant, 28. 

Verruca, 633. 

Vertebrae, congenital dislocations of, 52. 

Vertebrae, consolidation of, 9. 

Vertebrae, development of, 8. 

Vertebral column, pliability of, in in- 
fants, 8. 

Vertebral column, proportions of, in in- 
fants, 8. 

Vesical calculi, 356. 

Vesicles, seminal, absence of, 51. 

Vierordt's table of percentage of 
weights of organs, 2. 

Visceral haemorrhage, in new-born, 55. 

Volvulus, 180. 

Vomer, 4. 

Vulva, congenital deformities of, 48. 

Vulvo-vaginitis, 361. 

Wahl's sign, 180, 181. 

Warts, 633. 

Waxy liver, 145. 

Waxy spleen, 151. 

Weaning, 93. 

Webbed fingers, 52. 

Webbed toes, 52. 

Weil's disease, 535 ; differential diagno- 
sis, 536 ; lesions, 535 ; symptoms, 535 ; 
treatment, 535. 

Werlhof's disease, 349. 

Werner-Schmidt method of cream an- 
alysis, 75. 

Wet-nurse, 77. 

Whooping-cough, 443. 

Winckel's disease, 65. 

Wrist, congenital dislocations of, 52. 

Wrist, congenital dislocations, varieties 
of, 52. 

Yellow atrophy, acute, of liver, 143. 



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